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Steve ArnoldDavid Monk

DH West Midlands

Developing and Implementing Local Alcohol Treatment

Pathways

Workshop - 18th January 2009

Alcohol Treatment Pathways – Workshop Programme

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Developing and Implementing Local Alcohol Treatment Pathways18th January 2010

Government Office for the West MidlandsBirmingham

Damian MitchellAlcohol Improvement ProgrammeDepartment of Health

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Early Implementation PCTs

NHSPlanned delivery on RA-RHAs

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Prio

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learning

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Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc

Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc

PCTs (Unplanned) delivery on targets through implementation of elements of

the high impact actions

learningAlcohol Interventions Improvement Programme

Enabling changePriority support to Early Implementation PCTs.Tools: Learning sets, collaboratives, etc

Learning CentreCollects, 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

Rev

iew

S

uppo

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Regional co-ordinators (DH/SHA)

Responsibility to ensure delivery of

targets

learning

National Alcohol Improvement Programme

DH Policy TeamRole: Work with outside bodies to facilitate frontline delivery. Develop policy, Develop Guidance, Commission, co-ordinate and contract manage support projects and channel expertise

lear

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NWPHO

Provide local data on need and key evidence

Start delivering RA-RHAs

Receive priority support from AIIC

Implement High Impact Changes

Sup

port

In

fluen

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Social Marketing Insight, evidence, products and interventions

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21/04/23

http://www.alcohollearningcentre.org.uk/

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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110423

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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.

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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.

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Developing Alcohol Treatment Pathways - ChecklistDon 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

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Developing Alcohol Treatment Pathways – Key ElementsDon 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.

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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.

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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 interface13

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

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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

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Adults 16-64 visiting GP

Requesting help with alcohol problem

New Registration Other health complaint

Full ScreenAUDIT

AUDIT Score8-15

Increasing-risk

Full Assessment

Consider Referral to Specialist Services

ExtendedBrief Advice

AUDIT Score16-19

Higher-risk

AUDIT Score20+

Possible Dependence

AUDIT Score 0-7

Lower-risk

Primary Care - Alcohol Care Pathway

No action

PositiveResult

NegativeResult

SASQ FAST AUDIT - C AUDIT - PCInitial Screening Tools

Brief Advice

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ATP 1

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ATP 2Part 1

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ATP 2Part 2

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ATP 3

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ATP 4

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ATP 5Part 1

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ATP 5Part 2

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Developing Alcohol Treatment Pathways – Final thoughtsDon 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

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• 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 PathwaysWhat Else Might be Useful?

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• 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 PathwaysWhat Else Might be Useful?

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• 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 PathwaysLocal Experience in the West Midlands (1)

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• 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 PathwaysLocal Experience in the West Midlands (2)

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Access,Entry &Re-entry

Segmentation

Formulation

DIAGNOSIs

CareCurrency

CLUSTERS

Knowledge of people needing services

1.Quality of InformationSignposting

‘Ease of entry’

2.The Assessment Process

Right 1st timeDynamic

Exit&

Aftercare

3.The Delivery

ExperiencePersonalised

care packages

4.InformationPlanning

Signposting‘Ease of Exit’

Currency

Currency

Currency

Currency

5. Care CoordinationNavigation and Advocacy

Developing Alcohol Treatment Pathways – Generic Approach (1)

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Review(local

context)

Clear objectives

The evidence

Innovation

Barriers

Enablers

A clear strategy

Developing Alcohol Treatment Pathways – Generic Approach (2)

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• 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)

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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

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Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work - Briefing

• 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'

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Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (1)

• 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

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Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (2)

• 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’

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Developing Alcohol Treatment Pathways – Local Treatment Pathways – Group work – Summary of Key Messages (3)

• 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

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Developing Alcohol Treatment Pathways – Local Treatment Pathways – Action