1. 1 Steve Arnold David Monk DH West Midlands Developing and Implementing Local Alcohol Treatment Pathways Workshop - 18 th January 2009

2. Alcohol Treatment Pathways – Workshop Programme 2

3. Developing and Implementing Local Alcohol Treatment Pathways 18 th January 2010 Government Office for the West Midlands Birmingham Damian Mitchell Alcohol Improvement Programme Department of Health 3

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5. Early Implementation PCTs NHS Planned delivery on RA-RHAs Implementation Support Priority access learning Evidence Trailblazers (SIPS), ANARP Effectiveness review, HES data,etc Trailblazers (SIPS), ANARP Effectiveness review, HES data,etc PCTs (Unplanned) delivery on targets through implementation of elements of the high impact actions learning Alcohol Interventions Improvement Programme Enabling change Priority support to Early Implementation PCTs. Tools: Learning sets, collaboratives, etc Learning Centre Collects, co-ordinates and disseminates learning and good practice. Tools: SIPS toolkits, HuBCAPP, e-learning resource NST(DH) Supports 18 struggling PCTs P.A. Strategic reports & follow-up visits Review Support Regional co- ordinators (DH/SHA) Responsibility to ensure delivery of targets learning National Alcohol Improvement Programme DH Policy Team Role: Work with outside bodies to facilitate frontline delivery. Develop policy, Develop Guidance, Commission, co-ordinate and contract manage support projects and channel expertise learning NWPHO Provide local data on need and key evidence Start delivering RA-RHAs Receive priority support from AIIC Implement High Impact Changes Support Influence Social Marketing Insight, evidence, products and interventions 5

6. 08/10/2015 http://www.alcohollearningcentre.org.uk/ 6

7. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPo licyAndGuidance/DH_110423 7

8. Developing Alcohol Treatment Pathways – Introduction (1) Don Lavoie – DH Alcohol Policy Team Alcohol Treatment Pathways (ATPs) are locally agreed templates for best practice They map out the local help available for alcohol-related problems at the various stages of a treatment journey. They are commonly made up of a flow diagram showing the particular pathway and decision points Alongside the diagram is background documentation giving explanatory narrative and clarifying details This allows for a wide variation in size, scope and detail. 8

9. Developing Alcohol Treatment Pathways – Introduction (2) Don Lavoie – DH Alcohol Policy Team Builds on locally agreed protocols and developed treatment guidelines Supports more standardised local practice Provides practical help and guidance to less experienced workers. An ATP is not a substitute for management, supervision and training, But an ATP does offer a means to help ensure consistently high standards of treatment and care. 9

10. Developing Alcohol Treatment Pathways - Checklist Don Lavoie – DH Alcohol Policy Team ATPs should be: –agreed and developed locally, taking account of local service configuration and priorities; –evidence-based; –client-focused; and –agreed and championed so as to ensure ownership by managers, practitioners and the key stakeholder who can influence success 10

11. Developing Alcohol Treatment Pathways – Key Elements Don Lavoie – DH Alcohol Policy Team Reviewing the existing documentation, and the processes and pathways currently in use Developing or revising local treatment guidelines and protocols Deciding on the content of the ATP document – what we need to know and what would be helpful to know and include Producing clearly written documents that are easy to understand and are user-friendly –effective editorial control from the ATP lead or champion is needed – alongside involvement of all stakeholders on drafts; and Comparing new drafts with existing paperwork, removing duplication and including essential new content. 11

12. Developing Alcohol Treatment Pathways – Narrative (1) Don Lavoie – DH Alcohol Policy Team Purpose: Provides clarity as to the type of client the alcohol treatment intervention caters for States what the client can expect treatment services to provide – including important detailed practical arrangements when appropriate Sets out the roles and responsibilities of the service within the integrated care system towards the individual client. 12

13. Developing Alcohol Treatment Pathways – Narrative (2) Don Lavoie – DH Alcohol Policy Team Content: Definition of the treatment interventions provided (referencing any key guidance or guidelines) Aims and objectives of the treatment interventions Definition of the client group served Eligibility criteria (including priority groups) Exclusion criteria or contraindications Referral, screening and assessment processes Process for agreeing the treatment goals Description of the treatment process or phases Description of the co-ordination of care Nature of departure planning, aftercare and support Relevant onward referral pathways Description of the range of services/agencies with which the interventions interface 13

14. Developing Alcohol Treatment Pathways – Exemplars (1) Don Lavoie – DH Alcohol Policy Team Five specimen template alcohol treatment pathway diagrams. The diagrams will rarely make complete sense out of the local context The aim of the examples is to identify the shape of some typical ATPs whilst recognising the scope and level of detail will vary markedly from place to place They are not intended to be prescriptive– but rather to be illustrative of issues that may be of relevance in developing different ATPs In addition to the diagrams, some narrative commentary is given for each pathway, pointing out some issues that may need to be considered or addressed 14

15. Developing Alcohol Treatment Pathways – Exemplars (2) Don Lavoie – DH Alcohol Policy Team Currently available: –Identification and brief advice (IBA) –Community based services - assisted alcohol withdrawal –Assisted alcohol withdrawal – inpatient-based –People with combined alcohol and mental health problems –Homeless people who need alcohol treatment For further consideration: –Residential rehabilitation –People with alcohol problems who also experience domestic abuse –Service users in drug treatment who also have alcohol problems 15

16. Adults 16-64 visiting GP Requesting help with alcohol problem New RegistrationOther health complaint Full Screen AUDIT AUDIT Score 8-15 Increasing-risk Full Assessment Consider Referral to Specialist Services Extended Brief Advice AUDIT Score 16-19 Higher-risk AUDIT Score 20+ Possible Dependence AUDIT Score 0-7 Lower-risk Primary Care - Alcohol Care Pathway No action Positive Result Negative Result SASQFASTAUDIT - CAUDIT - PC Initial Screening Tools Brief Advice 16

17. ATP 1 17

18. ATP 2 Part 1 18

19. ATP 2 Part 2 19

20. ATP 3 20

21. ATP 4 21

22. ATP 5 Part 1 22

23. ATP 5 Part 2 23

24. Developing Alcohol Treatment Pathways – Final thoughts Don Lavoie – DH Alcohol Policy Team The way in which ATPs are developed locally will depend on the issues that have been identified as most important for which the development of ATPs are considered a useful contribution Planning the development of ATPs over a sensible timeline will be needed in order to ensure that high quality and robust ATPs are developed rather than simply quickly achieving a comprehensive but superficial coverage of topics It is important for all the key contributors to the care described in any particular ATP to be engaged in the development of that care pathway, at least at key development points and for final sign-off Establishing effective treatment pathways can therefore also involve developing and strengthening partnerships between relevant local organisations ATP development can be a helpful mechanisms to involve service users and carers in governance processes 24

25. Access to good data and combined intelligence –PH/quality observatory –Benchmarking capability –NI 39 groups –Learning sets –Gaining collaborative advantage –Using map of medicine – getting alcohol pathways on this resource The Royal Colleges - ‘expert power message’ Better local modelling Consistency of the ‘science’ – social market messaging e.g. pregnancy Balance between ‘crime and health’ consequences in the marketing imagery A minimum unit price National Minimum Dataset for A&E to include ‘Alcohol’ related diagnoses Developing Alcohol Treatment Pathways What Else Might be Useful? 25

26. QOF requirement – DH to lobby Positioning of alcohol advertising (NB new campaign form February 2010) CQUIN requirements – national, regional and local incentives QIPP/QaP Innovation funds – available through SHA’s Links to other initiatives, e.g. –Links to the ‘Quality’ agenda – advancing quality via Pathway Metrics, Clinical engagement and User experience –Need to lobby for ‘Alcohol’ awareness across all services (similar to e.g. work on Medically Unexplained Symptoms) –Mental Health service use of GPs with a special interest in Psychiatry Developing Alcohol Treatment Pathways What Else Might be Useful? 26

27. Sandwell (Neil Parkes): –Overview pathway supported by specific pathways for: GP/Self Referral to Tier 2 Services Tier 2 services (designated provider) Referral to Tier 3 A&E Referral and A&E Attendance Generic inpatient services Tier 3 service (designated provider) –Framed around the NHS but other agencies provide support –Interagency Alcohol group established from January 2010 – will help to formalise work done so far –SLA in place for Tier 2 services – under development in respect of Tier 3 –The ‘Pathway’ is not the only output – improving the process of working together through experience is a key deliverable Developing Alcohol Treatment Pathways Local Experience in the West Midlands (1) 27

28. North Staffordshire (Tim McGreggor) - new model for commissioning services to reduce alcohol related harm in the South Staffordshire: –Build on recent needs assessment and utilise the DH Ready Reckoner and Rush Model tool –Bring together key players to achieve ownership –Invest time with Practice Based Commissioners to ensure PCT ownership –Integrated pathways reflect the DH Local pathways document –ICPs need to go through PCT PECs –Difficult to move investment out of mental health trusts as it is part of a bigger lock contract –Need to work very closely with drug commissioners to check for impact or disinvestment in drug treatment services –Inpatient detox needs to addressed at a regional level Developing Alcohol Treatment Pathways Local Experience in the West Midlands (2) 28

29. Access, Entry & Re-entry Segmentation Formulation DIAGNOSIsDIAGNOSIs Care Currency CLUSTERSCLUSTERS Knowledge of people needing services 1.Quality of Information Signposting ‘Ease of entry’ 2.The Assessment Process Right 1 st time Dynamic Exit & Aftercare 3.The Delivery Experience Personalised care packages 4.Information Planning Signposting ‘Ease of Exit’ Currency 5. Care Coordination Navigation and Advocacy Developing Alcohol Treatment Pathways – Generic Approach (1) 29

30. Review (local context) Clear objectives The evidence Innovation Barriers Enablers A clear strategy Developing Alcohol Treatment Pathways – Generic Approach (2) 30

31. Clarity about population targeted A good case behind choices –Strategic analysis –Knowledge of stakeholders –High level health economic case well made and understood –Understand the policy competition Innovation (and funds) Evidence of what works Quality of assessments Choosing the right intervention Developing Alcohol Treatment Pathways – Generic Approach (3) 31

32. Working in designated groups: Identify any key local implementation issues Begin the preparation of a local action plan Consider further action beyond the workshop, inc any joint working and external support required Keep written notes of the key points Summarise the 3 key messages 32 Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work - Briefing

33. Starting with a Simple pathway makes sense – the basis for a sensible dialogue with stakeholders Learn from experience – create the environment to share knowledge Up our game on information, data and its utility - ‘better metrics - better ‘Commissioning' 33 Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (1)

34. Better stakeholder buy in – ‘right people engaged at right time’ - a clear business case Understand the resource implications in more detail – understand demand and the time it takes (time-lag) to realise a return Realism in the pathway - linking with other pathways where it makes sense e.g. Sexual health pathways 34 Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (2)

35. Leadership vital – on the payroll and driving the issue - Alcohol champions across partners Good local needs assessment driving commissioning and better benchmarking Learning exchanges – ‘more sharing’ – roll for the RAM to ‘match make’ 35 Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (3)

36. PCTs to consider options for joint working on the further development of ATPs e.g. –Region-wide user support group –Sub-regional geographic groups –PCTs at the same stage of preparation work together Initial assessment of current position in each PCT to be undertaken to inform the process – Deryn B to lead, using the recently developed PCT self-assessment tool or similar Regional support to continue for local initiatives via Deryn B The ALC team to provide dedicated website space for the West Midlands, enabling storage of locally developed pathways 36 Developing Alcohol Treatment Pathways – Local Treatment Pathways – Action