Inspecting the field - Harm Reduction and Commissioning Systems
Monday/12/May 2008 Filed in:
Drug Treatment
- Local
Partnerships and Administration
You'd be
forgiven for missing it in the hoo-haa about cannabis
reclassification, but on the exact same day as the ACMD published
their report into cannabis and the powers that be said "so what",
the Healthcare Commission and the NTA published their latest
Improvement Review report.
Although the report is a single document, it actually refers to two
themed reviews within the same programme - one of Harm Reduction
Services and one of Commissioning Systems.
The process works like this ... First of all supported by an expert
group, the NTA builds an assessment framework that looks at what
the key features and outcome of the theme area should be - you can
find them here. Local
partnerships and service providers submit their responses to the
assessment through an online tool. In addition data from NDTMS,
the 2006 NTA survey of services users
and the 2006/7 treatment plans is also used to assess performance. Local areas
are then marked "Weak", "Fair" "Good" or Excellent" across a range
of criteria.
Following the review the weakest 10-15% of areas are required to
prepare and implement an improvement action plan.
This type of process is obviously only as good as the questions
that are asked and the honesty of the replies by service providers
and local partnerships - and it is clear that while efforts have
gone into assuring quality, this research relies on self
assessment, uses a number of data sources of variable quality and
is based on some assumptions about effectiveness which are not
necessarily as robustly 'proven' as they might be. That said, this
is an ambitious piece of work of which the originators - the NTA
and the Healthcare Commission - should be proud. Its probably the
best we're going to see for some time as a snapshot of harm
reduction across the country and will help us direct other pieces
of work around commissioning systems and partnerships (like that by
the NAO and the Cabinet Office) more effectively.
The Commissioning Systems Review looked at 6 key
areas:
- Strategic Partnership
- Needs assessment
- Compliance with national frameworks
- Competent contracting
- Performance management
- Competent commissioning
In terms of strategic partnership, concerns were identified regarding the seniority of those attending DAT meetings - with 36% of DATs scoring as "weak" on this point, 48% "fair" and only 11% and 5% "good" or "excellent".. This is something that been noted for some time - with many DATs claiming that senior people simply don't turn up to the DAT meeting and their junior representatives are unable to make commitments or decisions. When you talk to DATs about this they tell you its because the DAT isn't as important as the CDRP, that the agenda is very centrally driven - with little local flexibility and so there are few local decisions to make. A couple of senior officers who would have attended DATs have confided to me that the discussion is really technical - covering areas they don't and can't have expertise on, in detail and so they no longer see the DAT as a strategic body and don't make it a priority. One Director told me that when all that defined a DAT as effective was "the absence of a snarling letter from the NTA" she couldn't see the point of getting involved. Whatever their reasons, this is an area in which there needs to be progress if the local agenda is to work effectively.
The involvement of providers in the commissioning process on the other hand was encouraging, with nearly 100% of commissioners saying they met and consulted with providers regularly. When Joint Commissioning Managers were asked to comment on levels of user and carer involvement in their commissioning processes, over 94% said they had meetings with service users around their annual commissioning plans - which is excellent.
In terms of needs assessment the inspection found significant shortfalls - while 79% of DATs had undertaken a needs assessment, only 1% of areas were judged to be "excellent" on this criteria, 21% "good", 52% "fair" and 26% "weak". The assessment of compliance with national frameworks such as models of care was based on a number of criteria including waiting times, care planning, retention, planned discharge, and residential services. It seems to me a huge number of assumptions underpin the choice of these criteria as the key indicators here - most importantly, they assume a positive relationship between the divine troika of performance (retention, waiting times and planned discharge) and Models of Care Implementation - which in my experience isn't as straightforward as it may at first seem. However 99% of DATs meet 75% of the retention targets and 64% of DATs scored "good" or "excellent" on waiting times - though a worrying (given that this has been a focus of the system for many years) 21% were "weak".
Commissioning of residential services was shown as being non compliant with NTA/Home Office guidance - with 35% of areas not having appropriate contracts in place including requirements for aftercare etc. The care planning question ("How many service users in structured treatment, who commenced in treatment in 06/07, have a care plan?") was partly based on responses to the 2006 NTA user satisfaction questionnaire. This had quite a patchy response so the results need to be viewed with some caution - however the fact that only 26% of local partnerships scored "good" or "excellent" in terms of care planning (and that's just in terms of their existence, not their quality) is concerning if we are to move to a more individualised and ultimately more personalised treatment system. It would be interesting to know what the different responses are to this question for service users at different stages of their treatment journey.
I know many providers will be interested in the section on commissioning practice - and it is worth a read - or it would be if a really important bit of it hadn't gone wrong. Originally the review was going to ask voluntary sector providers about whether treatment was being commissioned from the in line with the National Compact for the Voluntary Sector. Unfortunately the question was phrased wrongly and the answers that came back could not be analysed. The HCC and the NTA are disarmingly honest about this shortfall in the report. Hopefully a separate piece of work can be undertaken to look at this critical issue - maybe also bringing in some analysis of whether there is any inbuilt advantage over the voluntary sector for NHS and statutory organisations tendering for contracts with local partnerships and PCTs. The levelling of the playing field will be an important part of achieving the cost savings and efficiencies the drug treatment system needs if we're to survive on a standstill budget. While the role of the plural market in ensuring quality has yet to be proven, in the drugs field better than many other areas we are beginning to understand the danger of monopoly provision.
Workforce development was shown as "weak" in 37% of local drug partnership areas. This is unlikely to be the complete picture. The review only looked at whether a workforce strategy was in place - not whether it was being implemented or was any good - so there may be more stones to pick up here!
Performance management was an area that almost all partnerships scored well on (though how you can score well on performance management but badly on needs assessment is somewhat baffling - surely if you don't know what need is you can only measure performance through some very narrow and subjective criteria!). 80% of DATs responded to the last health care commission review by putting an action plan in placer to address shortfalls - which means that people in local areas are listening and responding.
Interestingly 85% of joint commissioners were able to assure the HCC and the NTA that the NTA quarterly performance report was utilised at a senior strategic level. This is encouraging though somewhat at odds with the earlier finding that only 11% of DATs score well on having senior level representation! Maybe they do it via vulcan mind meld? This issue is also picked up in the final criteria for this section that explores the level of senior engagement in commissioning decision making - once again the survey picked up a significant lack of multi agency engagement with commissioning decisions - largely due to lack of seniority of those attending commissioning group meetings - the report concluded " This lack of seniority clearly has the potential to compromise the effectiveness of local drug partnerships in addressing drug-related need"
In terms of competency of commissioners themselves (assessed by reference to their training and/or experience) while 25% of areas scored "excellent" on the competency of their commissioners - "20% of local drug partnerships did not have commissioners who were competent ... in the following competencies: drawing up service specifications, inviting tenders and awarding contracts, monitoring and evaluating the quality outcomes and cost effectiveness of services and in procuring services" One hesitates to ask what these areas had instead - possibly people who just make a damned fine cup of tea - or maybe they are unable to fill posts? What is it about the drug treatment field that means we seem unable to attract either senior level representation at either strategic or commissioning group level, or keep hold of good commissioners?
Finally this section looked at the satisfaction of service users with services (though again only by using the NTA 2006 service user questionnaire results, which had a very small and patchy response rate, so regard this with caution!). 28% of local areas were scored as 'weak in terms of service user satisfaction with local services, with 52% scoring "fair" and 19% scoring "good". Just 1% of local areas scored "excellent" on this criteria.
The Harm Reduction Review looked at 4 key areas.
- The extent to which harm reduction services are embedded in the whole treatment system
- Prompt and flexible access to interventions like needle and syringe exchange
- Action by providers to reduce drug related deaths
- Competence around harm reduction in drug service staff
In terms of access to harm reduction services, the biggest shocker was the fact only 1.7% of areas opened most of their needle exchange services after 7pm, only 21% on Saturdays and only 2% on Sundays. 95% of areas scored "weak" on testing and treatment for Hepatistis C - only 3% scored "fair" and 1% scored "good". Despite the fact that 65% of partnerships have hepatitis C testing and treatment protocols, the national mean for injecting drug users who'd been tested for Hep C was 21.5%. That's a hell of a lot of areas with great protocols and - well not much action. On the plus side, most areas were found to have an excellent range of services available in the pharmacies and specialist needle exchanges they do run. So I guess the picture's not so bad if you read strategy, only inject between 9am and 7pm Monday to Friday and don't (unlike 1 in 4 of injectors in London) have Hepatitis C. In terms of Hep B, 95% of partnership areas offered under 75% of service users a hep B vaccination - or to put it another way in nearly all areas at least 25% of people in treatment are not offered vaccination against this preventable disease.
There is some comfort in the section on Drug Related Deaths where we find out that while only 68% of areas have multi agency strategic plans for dealing with drug related death and on the indicators chosen to represent activity - paramedic naloxon training, overdose training for custody officers and overdose training for service users and carers, the majority of areas scored "excellent" or "good". It would be interesting to look at the actual drug related death rates alongside these reports.
The final harm reduction criteria chosen was about staff competence in harm reduction and looked firstly at protocols for staff safety in terms of BBVs. 52% of areas scored "excellent" for this with only 6% scoring as "weak". Training for staff in non pharmacy based needle and syringe exchanges was assessed as "good" by the JCMs in 59% of areas. However staff working in specialist community prescribing services were assessed in 17% of areas as "weak" and 26% of areas "fair" in providing harm reduction interventions. In particular the review notes shortfalls in wound care, supply and exchange of equipment and supporting people to monitor their own healthcare. One wonder what exactly they are doing - you have to hope (but somehow doubt) that these are the areas in which pharmacy exchange is working well. Most depressing was the extent to which service users expressed that they did not feel respected by pharmacy staff. The report concludes that this is because insufficient training has been provided to pharmacy staff as opposed to pharmacists themselves. I suspect its a natural impact of the increased demonisation of drug users over the past ten years. Whatever the reason, 30% of areas scoring poorly on this is quite shocking - and dangerous.
The report concludes its harm reduction section by noting that many service users do not feel that harm reduction services are comprehensive and that there is indeed a clear national shortfall in the provision of out of hours needle exchange.
As you read the reports you can't help but feel that this review has only teasingly scratched the surface of these two important areas. The focus on the activities of the local partnerships is appropriate, but it would be interesting - particularly in terms of the harm reduction theme - to explore the extent to which harm reduction has been championed by central government and the NTA, the level of funding and monitoring of harm reduction initiatives over the past few years and the priority given to it within the overall performance management of the drug treatment system. The report mentions that the results of the reviews will provide an interesting baseline for the DH Drug Related Harm Action Plan - once it gets off the ground. But maybe there's something about the low priority of the DRD Action Plan for Government reflected in the local response? To be fair to the NTA they have recently given this area more attention - explaining that one of the things that stopped them being able to get to grips with the priorities of the action plan sooner was the media attention they received last year about the treatment system and the difficulties of managing European tender regulations (something according to the review that some DATs handle quite well incidentally, and all DATs who want to re-commission have to deal with). They have now said that the work due to commence last autumn - including the national targeted campaign will now be begun with vigour - and the campaign will be launched in the autumn.
One of the fascinating things about both reports are the signs that - in terms of strategy and planning - many DATs are following the processes laid down, but the processes aren't delivering the results we need them to. I remember attending a brilliant NTA event - Opening Doors - way back in 2002 which introduced process mapping to the drugs treatment field. One of the things they drilled into us was the Don Berwick first law of improvement - that "every system is perfectly designed to produce exactly the results it does" In other words, a system that achieves a disconnect between strategy and delivery is set up to do just that. To change the outcome, you must redesign the system. Trying harder at your old system will never work.
The issue of senior level representation on DATs and senior engagement in commissioning decisions reveals much about the status of drug issues locally. We need to understand more about this if we are to implement the localist approach of the National Drug Strategy. DATs were one of the first local multi agency partnerships funded via a centrally pooled budget in the UK - slowly beginning to commission and direct local services after the 1998 strategy. Somehow we have let them slip away. Maybe the (some would say) necessary central direction of the past few years really has turned the DAT into little more than an animated filing cabinet. Certainly the level of centrally required and monitored plans seems to be increasing exponentially again - despite the mainstream focus on reducing the planning burden. Maybe, as an old friend of mine used to observe, when you fence in all the prairies, you lose the pioneers and simply get a load of cowboys.
I don't know.
What I am sure of is that to make the new drug strategy work we need a new investment in local partnership - and that means a relaxation by the centre in terms of process management and reporting - this is difficult to do at a time when confidence in DATs is low. However with some investment in promoting local responsibility and establishing some meaningful local outcome measures (what a shame we missed the chance to do this last year!) it could be achievable.
The next set of HCC reviews is the last. This is a shame - all the reviews have provided us with some fascinating - if occasionally superficial - information. Maybe though, a step back from thematic inspection will bring us a step closer to inspection of drug services as part of the mainstream work of the new merged inspectorate next year - including planned and unplanned inspection and self regulation against a robust quality standards framework. Lets wait and see .....