Will the NTA self-audit tool challenge shared care

1. Will the NTA self-audit tool challenge shared care? Self audit tool to support the planning, commissioning and monitoring of primary care components of adult drug treatment systems NTA October 2008 Hope you have had an opportunity to read through this document The document is in three part Firstly an introduction as to why the NTA has prepared a self audit for shared care Secondly guidance as to how to complete the self audit Thirdly the audit itself � with the standard to be measured, the lead person responsible for that standard and whether it has been meet. Hope you have had an opportunity to read through this document The document is in three part Firstly an introduction as to why the NTA has prepared a self audit for shared care Secondly guidance as to how to complete the self audit Thirdly the audit itself � with the standard to be measured, the lead person responsible for that standard and whether it has been meet.

2. Introduction �Primary care services, delivered alongside specialist drug treatment services, are an essential component of an effective integrated adult drug treatment system that is able to meet the demands for the overall capacity, quality and range of services and interventions that are provided to drug misusers.� The introduction recognises that primary care services important for adult drug treatmentThe introduction recognises that primary care services important for adult drug treatment

3. What is shared care? The Department of Health defines shared care as: �The joint participation of specialists and GPs (and other agencies as appropriate) in the planned delivery of care for patients with a drug misuse problem, informed by an enhanced information exchange beyond routine discharge and referral letters. It may involve the day-to- day management by the GP of the patient�s medical needs in relation to his or her drug misuse. Such arrangements would make explicit which clinician was responsible for different aspects of the patient�s treatment and care. These may include prescribing substitute drugs in appropriate circumstances.� Reviewed shared care arrangements for drug misusers. London: Department of Health, 1995 (Executive letter; EL(95) 114). The audit tool refers to EL (95) 114 � which describes shared care as this: Joint participation Planned delivery of care Enhanced exchange of informationThe audit tool refers to EL (95) 114 � which describes shared care as this: Joint participation Planned delivery of care Enhanced exchange of information

4. What is shared care? �There are a wide range of models of shared care, which may include the following variations: GPs or non-medical prescribers commissioned as providers of drug treatment, and depending on arrangements and level of competence, offering different levels of care from long-term maintenance prescribing in shared care arrangements to more specialised packages of care for complex needs. Drug treatment delivered from a base in a primary care setting by a multidisciplinary team, to patients registered with those GPs or patients registered with other GPs in the locality. Support for specialist provision from primary care, or more usually secondary care-led services, which provide shared care support and direct care for more severe and complex cases Arrangements set up to deliver services to specific vulnerable patient groups, such as homeless people, refugees and sex workers. These services will be based in primary care and provide a range of services including drug treatment and have often been commissioned as personal medical services. They are supported by specialist secondary care drug services, which provide direct care, particularly for more severe or complex cases. Whatever models of shared care are commissioned locally, they should be commissioned according to local needs, and in line with medical competences and appropriate clinical governance arrangements. These shared care arrangements should be reviewed, refined and developed regularly.� Models of care for drug misuse, 2006 The introduction recognises that �shared care has changed�. The three other documents it quotes do not seek to try to define shared care, but do illustrate the variety of different types of care which may be offered to patients This is from Models of Care for Drug Misuse Drug Misuse and Dependence UK Guidelines on Clinical Management 2007 Best Practice Guidance for Commissioners and Providers of Pharmaceutical Services for Drug UsersThe introduction recognises that �shared care has changed�. The three other documents it quotes do not seek to try to define shared care, but do illustrate the variety of different types of care which may be offered to patients This is from Models of Care for Drug Misuse Drug Misuse and Dependence UK Guidelines on Clinical Management 2007 Best Practice Guidance for Commissioners and Providers of Pharmaceutical Services for Drug Users

5. Why has shared care changed? Several changes in primary care contracting have been implemented by the Department of Health in the last few years, for example: Targeting specialised areas of care e.g. Personal Medical Services, (PMS) 1990s Performance management for primary care e.g. GP Contract (nGMS) 2004 and Pharmacy contract Best Practice Guidance for Commissioners and Providers of Pharmaceutical Services for Drug Users Non-Medical Prescribing, Patient Group Directions And Minor Ailment Schemes In The Treatment Of Drug Misusers Opening up the primary care arena to new providers e.g. Alternative providers of Medical Services (APMS), Social Enterprises; Community Interest Companies Implementing care closer to home: Convenient quality care for patients. Part 3: The accreditation of GPs and Pharmacists with Special Interests (DH 2007) Why has shared care changed? The document lists some of the drivers which have lead to this change However what will act as drivers are NTA documents. This self audit tool will be used by commissioners to measure their services Why has shared care changed? The document lists some of the drivers which have lead to this change However what will act as drivers are NTA documents. This self audit tool will be used by commissioners to measure their services

6. Partnership? �This self audit tool is provided to support local partnerships with the development, planning and commissioning of primary care based services as part of an integrated adult drug treatment system.� �Strategic partnerships are responsible for joint planning and decision making, which shapes the context within which services operate. This kind of partnership working may also involve a financial or statutory element. Examples of strategic partnerships include: � drug action teams (DATs) � crime and disorder reduction partnerships (CDRPs) � local strategic partnerships (LSPs). The work of drug services is likely to be directed by these partnerships because of their power and influence, including commissioning and funding. However, some drug services may also be actively engaged within these partnerships or their advisory bodies.� Developing drug service policies. Briefing no. 8: Working in partnership National Treatment Agency, London, April 2005. One difficult I had was understanding what the document meant by �partnership� This definition comes from another NTA document In effect any organisation or body who is working with drug usersOne difficult I had was understanding what the document meant by �partnership� This definition comes from another NTA document In effect any organisation or body who is working with drug users

7. Strengths of primary care based drugs services Increased overall capacity Increased accessibility for patients Freeing of capacity of specialist treatment services Reintegration of users within their communities Primary care team knowledge of service user�s family and locality to improve treatment Provision of general medical services Opportunity to address health inequalities The introduction lists the strengths of primary care drug services Are there any other strengths which the could be added to this list from this mornings discussions? Do we agree with the NTA Vote I want to rate these in order of importance � what do we feel as a group is the greatest strength? I want to repeat this � as a patient, what do we feel is the greatest strength? The introduction lists the strengths of primary care drug services Are there any other strengths which the could be added to this list from this mornings discussions? Do we agree with the NTA Vote I want to rate these in order of importance � what do we feel as a group is the greatest strength? I want to repeat this � as a patient, what do we feel is the greatest strength?

8. Weakness of primary care based drugs services Ask for ideas Fragmentation of servicesAsk for ideas Fragmentation of services

9. What are we auditing? STRATEGIC MANAGEMENT Strategic/ Monitoring Groups (- would normally be expected to be the body which completes this self-audit.) Partnership has a multi-agency strategic group responsible for overseeing the development and quality of primary care services (usually a Shared Care Monitoring group). PCT and Partnership receives quarterly primary care development progress report against adult drug treatment plan expectations and key priorities. Partnership receives and reviews clinical governance/quality assurance reports from primary care based drug treatment services. Leadership Partnership has a named lead/champion for primary care service development and quality (e.g. GP, Pharmacy lead or shared care co-ordinator). Care Co-ordination and Equity of Provision There are published care pathways which allow smooth criteria-led transfer of patients between primary and secondary/specialist care. There are defined arrangements for effective care co-ordination for patients accessing primary care services The Audit looks at 4 areas Firstly strategic management In that it looks at three areas, the strategic monitoring groups, the leadership and care co-ordinationThe Audit looks at 4 areas Firstly strategic management In that it looks at three areas, the strategic monitoring groups, the leadership and care co-ordination

10. How are we doing? STRATEGIC MANAGEMENT Strategic/ Monitoring Groups Do shared care monitoring groups work? What is their purpose? Are they the right group to undertaking this self-audit? Should they be providing progress reports back to the PCT and Partnership? Are they the right organisation to reviews quality assurance reports from primary care? Leadership Is a champion for primary care service development and quality necessary? Who should undertake this role? Can one person do it? Care Co-ordination and Equity of Provision Do we have care pathways and do they work? Does primary care have effective care co-ordination? Can we prove what we do?

11. What are we auditing? TREATMENT CAPACITY Commissioned primary care services A local expectation of the percentage of general practices and community pharmacies who provide services within a defined shared care arrangement. A local expectation of the percentage of general practices who are delivering primary care-based treatment within other commissioned service model Accessibility Gaps in coverage of primary care provision are identified and a local improvement expectation included in treatment plans. i.e. the aim is for all patients to be able to access primary care treatment within their community of residence once they are assessed as suitable. Balance of primary care based provision in the treatment A local expectation is set as to how much of the total adult community prescribing treatment capacity is provided by primary care Non commissioned primary care services Identify GP practices do not provide community prescribing outside of a commissioned service model. Secondly treatment capacity In that there are four areas, primary care services, accessibilty, the balance of primary care based provision and non commissioned primary care services Secondly treatment capacity In that there are four areas, primary care services, accessibilty, the balance of primary care based provision and non commissioned primary care services

12. How are we doing? TREATMENT CAPACITY Commissioned primary care services Do the shared care committees set levels of involvement? If not, who does? How can we reach them or exceed them? Accessibility How can we reach areas that are not covered? Balance of primary care based provision in the treatment Do we set levels? How do we set them? How can we reach them? Non commissioned primary care services Should GPs who are not part of commissioned primary care services be prevented from prescribing?

13. What are we auditing? 3. WORKFORCE DEVELOPMENT Primary care training The Partnership workforce learning and development strategy specifically includes primary care needs. Other primary care staff e.g. receptionists practice nurses, midwives and health visitors have access to relevant competency based training. Accreditation A local expectation of the percentage of practices where at least one GP has completed RCGP Part 1 Certificate in the Management of Drug Misuse or equivalent. (This should equate to or exceed, the number of practices providing commissioned primary care based treatment) A local expectation is set in relation to the percentage of community pharmacies where the regular pharmacist has completed RCGP part 1 certificate or CPPE certificate in substance misuse. A local expectation is set in relation to the number of GP�s who have completed Part 1 (or equivalent) and Part 2 of the RCGP Certificate in the Management of Drug Misuse or equivalent accredited training. Appraisal A local expectation is set in relation to the number of GPwSIs who have had an appraisal which specifically addresses the substance misuse part of their work. Clinical supervision Systems are in place to enable GPwSIs, Primary Care Addictions specialists and non medical prescribers to have access to clinical supervision and support from an appropriately qualified specialist. Third area of audit � work force development Covers primary care training, accreditation, appraisal and clinical siupervisionThird area of audit � work force development Covers primary care training, accreditation, appraisal and clinical siupervision

14. How are we doing? 3. WORKFORCE DEVELOPMENT Primary care training Is the funding for training of GPs and pharmacists? Is there funding for training of other primary care staff? How is ongoing CPD organised? Accreditation Have GPs and pharmacists been accredited? How do we encourage people to do part1 and then part 2? How is ongoing CPD organised? Appraisal Do GPwSI have appraisals? Are their appraisal systems in place? Clinical supervision Is there clinical supervision available?

15. What are we auditing? 4. QUALITY IN PRIMARY CARE BASED DRUG TREATMENT Primary care audit Primary care services have participated in appropriate levels of clinical audit of aspects of drug misuse treatment as defined in the guidance. Primary care prescribing policy A locally agreed primary care based drug treatment prescribing policy and shared care agreement is in place that is consistent with NICE and DH clinical guidelines. A locally agreed primary care based drug treatment prescribing policy has been approved via PCT clinical governance processes. Primary care participation in care planning process All participating primary care practitioners actively participate in local care planning processes Provision of general medical services All GP practices offer general healthcare to drug misuse patients All community pharmacies provide essential pharmacy services to drug users. Harm minimisation All primary care practitioners and GP practices, offer harm minimisation advice e.g. safer injecting advice, safe storage of medications and interventions e.g. BBV immunisation and testing in line with relevant clinical guidelines Finally quality of primary care services: Primary care audit, Primary care prescribing policy , Primary care participation in care planning process, Provision of general medical services and Harm minimisation Finally quality of primary care services: Primary care audit, Primary care prescribing policy , Primary care participation in care planning process, Provision of general medical services and Harm minimisation

16. How are we doing? QUALITY IN PRIMARY CARE BASED DRUG TREATMENT How can we improve quality? Primary care audit Are primary care services undertaking audit? Is the audit of suggested topic? How can they be encouraged to do so? Primary care prescribing policy Are there prescribing policies in place? Who has set these? Have these been agreed? Are they updated regularly? Do they follow appropriate guidelines? Primary care participation in care planning process Do GPs and pharmacists do care plans and TOPs? Should they be paid proportionately to care plans completed? Provision of general medical services Do GPs prescribing outside of their practice patients provide general medical services? Harm minimisation Does primary care provide a full range of harm minimisation?

17. Is shared care up to the challenge? The NTA is a driver for change in substance misuse treatment. This document seems to be aimed at shared care monitoring groups to ask them to consider how they are doing. In doing so shared care is being challenged to look at how it is doing? It is a self �audit � there are no prizes and no brickbats, but that is no to says there won�t be at some point in the future So how are we doing?The NTA is a driver for change in substance misuse treatment. This document seems to be aimed at shared care monitoring groups to ask them to consider how they are doing. In doing so shared care is being challenged to look at how it is doing? It is a self �audit � there are no prizes and no brickbats, but that is no to says there won�t be at some point in the future So how are we doing?

18. How are we doing? What do we do well? What are our challenges and why? How can we meet these challenges? Split into four groups We are all members of a �partnership� There is no reason why PANN should not be seen as part of your local partnership?Split into four groups We are all members of a �partnership� There is no reason why PANN should not be seen as part of your local partnership?