I work for a community drugs team and we are looking at developing long term strategies for working with clients who are stable on methadone/buprenorphine prescriptions. Clients who do not want/need counselling and have been risk assessed as stable but do not have shared care GPs. Does anyone have any working models for this less intensive element of care? Any evidence base for this work?
thanks.....

http://smmgp.groupee.net/eve/forums/a/tpc/f/1064030241/...911015812#1911015812

We tend to see people who are stable every 4-6 weeks.

Thanks for that, very very interesting. I am particularly interested in the Bimingham NAAF model and will be contacting Birmingham soon!

Hello.. birmingham calling. Yes, I was part of inventing the NAAF model, though not of choosing its name.

I have described it on here in the past, so probably possible to find the thread via a search. When we first started having surgery attached drug workers (??was it 5or 6 years ago.. time flies)I had some patients who I had been scripting on my own, in the old fashionned way, for the previous 20 years, who had stable lives and after initially meeting the drug workers, did not feel they needed any more support at that time. The managers of the drug workers then insisted on "closing their files" (not a concept we GPs understand very well) as they said they could not be "responsible " for people who were seeing me (for scripts) but not seeing the drug workers. I was not happy.

I was delighted when the first orange book guidelines came along and said that no-one should prescribe in isolation, and of course this was strengthenned by the Shipman case, so I sold the NAAF concept to the managers as being a need for the drug workers to check on the GPs, to make sure we were working within the guidelines. The more resistant patients were all told it was a scheme to police my work, and I wasn't allowed to do the work unless they saw a drug worker briefly every six months. gradually they have got used to it.

In practice, the drugworker takes a swab, fills in a care plan (which can just say "all is going well and no changes needed to script or life plan") and completes the NDTMS tickboxes. During this process, it sometimes becomes clear that the peron does in fact need more support or help in some area, in which case they can be quickly "un-NAAFed" and become active for a while.

If all is stable the patient will just see me for whatever is needed, until the next NAAF check. I probably see them every 6 or 8 weeks, because I like the regular life updates while I sign their scripts.

I strongly support the notion that everyone should see their prescriber in person at least every 13 weeks (as the guidelines recommend). There are some people who are the opposite of NAAF, with lots of trouble in their lives, and they may need weekly or two weekly psycho-social support and help from the drug workers, but do not need prescription changes, and may only need to see their prescriber every 12 or 13 weeks.

I think both drug workers and prescribers are limited resourses, and it is important to offer the services/treatment that patients need, at the correct time for it to be effective. Many of our patients need intensive help on a daily or weekly basis at times, and this is only possible if resources are not wasted on people who are in fact coping perfectly well with thier lives, as long as they have a script.

So the bottom line is.. I believe that very stable people who are coping with life on an opiate script should see the presciber face to face at least every 3 months, for medication review, and see the drug worker for NDTMS stuff and care plan writing and swab, at a minimum of every 6 months,.

Good concept judith,

Who determines who is a NAAF client? is it GP,Client/Patient?
Who is responsible for completeing the TOP on these clients that are seen every 3 months.
who is monitoring/liasing with the pharmacies to ensure compliance and patients are not missing collections

hello

The Naaf model is very interesting and appears to be very client focused with an assessment made of an individual's needs and the care allocated as appropriate but with the facility to alter the clients status and move them back to more intensive work. I'm also wondering if you have a formal risk assessment process/form to assess a clients NAAF status ( I think we would find another name!)

One other point. Does anyone have any experience of working with a team approach to this client group as opposed to a key working model?

Hi - it's really useful to consider different ways of working with different clients. One thing that comes across is that these clients are still on scripts, many may have had dispensing relaxed, and as a Prescriber I would agree with Judith that someone has to see their clients to check that all is in fact still stable. The other factor is resources - how often can keyworkers / doctors / nurse or non medical prescribers see their clients ? We have dilemma in another sense, that we have much less doctor time and some clients have not been seen face to face for over a year by their prescriber. No fault of the clinical input, but a resource problem, and one that needs to be understood when we are urged to attract more and more clients into services whilst budgets are constrained rather than expanded. As Prescribers we would also like to have more than our standard 10 minutes for a review and 20 minutes for complex or new client assessments ........ we live in hope ..... any thoughts on this ?
PS we already have 2 Nurse Prescribers on site who see the more stable clients regularly ( approx once every 3 - 4 months ) and have a good and well established shared care scheme which might take a few more clients, but progress is slow.

pardon me for being so cynical but we are being urged to see 'stable clients' less frequently so they are not tied to treatment etc, and we are seeing the more 'unstable clients' more frequently. There is an argument that would challenge the fact that when a client is 'stable' that maybe the time that they can be encouraged to detox,encouraged to reflect on their drug using lifestyle and maybe make changes, so at that point maybe more support would be beneficial, what do people think?

The eternal problem with dividing service users into “stable” and “unstable/complex” is that individuals often don’t conveniently remain within their classification and fluctuate from one to the other and whatever criteria we use are subjective to a greater or lesser degree. Even if a rating scale like Cristo is used when we arrive at an apparently objective rating each element has been assesses subjectively. Also, do we see those classified as stable less often or for less time when additional input at this stage may support them in moving on to that elusive “positive discharge”.

I totally agree Pat, my thoughts on this is that to see someone less often because they are'stable' is counter-productive, the reason being and, before I continue I accept there will always be a minority of people who will be in treatment indefinatly. But by seeing patients who are stable less often is to me a little like missing a great oppotunity to utilise interventions more effectively, we are keeping people in treatment by seeing them less frequently

Are we at risk of missing the patient out of this equation. What do they want/need?Presumably there is nothing from stopping people making contact and receiving an earlier appointment if they have an epiphany and want to make changes.
Or has change been missed off, see other posting re NA.

I agree with S purcell, the more stable clients probably are the ones who would benefit most from other interventions, and I guess this should be in the care plan, and kept under review ( care planning being the joint process that goes alongside the medical treatment ). And yes clients do move between categories. So where does that leave us ? The NTA, rightly in many cases, wants us to move people through treatment and out into employment and a drug free life. Resource issues will be even greater if we have an approach of keeping people in treatment if that's what they want, regardless of opportunities to move on. Mental health care has the same dilemma here - many people with less severe problems seem to be stuck in the unemployed, sick role and little work is done to help them move on ..... I am no fascist and realise that some people genuinely are not ready, but for some it is a reasonable thing to do, and it is perhaps a sensible way of allocating resources when we are constrained by budgets and expected to attract more clients into treatment.....

Suggesting to some that they might consider change is hardly fascist.It is the fear that it might be construed as such which is I fear preventing it being raised as a serious issue.
Perhaps we will have a special change specialist in the brave new world of Polyclinics.

Thank you, this conversion is really useful for me. I agree that seeing more stable clients less often is important as it frees up spaces for us to see the higher risk clients (drug use, no prescription or in titration) but to 'farm them out' seems unfair. I like the idea of a framework where a client has to be seen eg every three months but has a drop in facility to see a worker according to their needs and motivation. Again this makes me think that a team approach may work well, where clients do not see individual workers but instead see a member of the team who can support them, you lose the one on one relationship but gain the flexibility for a client to be seen when they wish.I worked with this model for a period in London and it worked well but was stopped when more workers were made available.Does anyone else have experience of this model?

I can see that from the system point of view, offering a drop in to the team would be easiest, but it might not in the end be the most effective, as the new worker would have to get to grips with what may be a long and complex past story.

Where possible I think it is always best for the person to have one named key worker for routine long term reviews as they can then say "how has the last six months been.. any changes in your life" and to be able to assess the person's wellbeing more quickly and effectively than someone who has never met them before.

I am sure that any team worker could help at a time of crisis, but for long term reviews the therapeutic alliance (whatever that is) and continuity of care have huge advatnages both for the patient and for the worker. (the reward of seeing someone who is doing well and progressing with their lives and is transformed from the struggling person you knew in the past is a delight for both parties, and is part of our wages)

hello, you are right! I agree, I think a team approach is a method to use only when you have a crisis level of reduced staff. The one on one with clients is a core part of what we do and it wouldn't be fair on a client or a staff member to lose this therapuetic relationship. However I am still left with the problem of having ever expanding client numbers and finite number of keyworkers. I guess gold standard would be to employ more key workers but until this happens what to do? Does anyone have any experience of a case weighting system where client numbers are allocated to staff on level of need rather than numbers alone?

Hi Campbell
Many services are having the experience of getting 'saturated' with longer term clients. i would suggest primary care based treatmenbt (aka 'shared care) is the way forward for many such clients, and that perhaps they could revert to specialist input when they become ready for bitg changes, in order to increase the input?
Yes we have experience of case weighting locally. if you would like to know more email me at susi.harris@calderdale-pct.nhs.uk and I will put you in touch with someone.


And Hi Pat, with my NTA hat on (just), I have to ask, why are you using the subjective Christo when you now have the objective and validated TOP??

Hi all, I had the great privilege to be Dr Yates' drug worker for almost 3 years, and was also involved in the evolution of the NAAF system (no, the name wasn't my idea either - I always took great pains to explain the acronym for fear of misinterpretation!)

So thought I'd put in my two penn'orth. I wanted to follow up some of the earlier comments.

Firstly, the instigation of the NAAF process is usually when a client themselves is requesting in words (or deeds) to be seen less often by the drugworker. This is then discussed between the GP, client, and drugworker (and drugworker's manager's approval sought). So this is a client-centred, client-prompted option.

No client is ever forced to be NAAFed, and no GP is forced to take NAAF responsibility for any client. All decisions are made on a case-by-case basis.

Not all NAAF clients are super-super stable. But where there is a clear aversion to drugworker input (it does happen!) and the GP is happy to keywork for a bit in order for the client to engage with drugwork support on their own terms, the half-hour brief-intervention format of the NAAF review appointment has been beneficial in building rapport and a therapeutic engagement between the client and their drugworker, who have then gone on to engage more fully. Sometimes it takes a few reviews (so more than a year) for a client to realise that drug workers don't have two heads or breathe fire and can actually be quite helpful!

In these circumstances, the prescriber does have to be willing to take on a lot more of the reviewing, risk assessing, and communicating with the pharmacy duties etc than they otherwise would, but in my experience, it is a way of engaging some clients who would otherwise struggle with more intensive engagement, but who then go on to embrace that more intensive engagement when they feel ready for it.

When NAAF is first being mooted as an option, it is explained to clients (and at every review) that they can elect to be seen sooner if they feel the need at any point. Clients can and do utilise this option when they feel they need more intensive support, perhaps at a time when they are out of work, contemplating detox, or would like a referral to another organisation. When they feel ready they are welcome to request to become re-NAAFed, and do. So it's a fluid status.

I take on board that the more stable clients should be encouraged to detox, and are, where appropriate. They're seen 4-12 weekly by the GP, and six-monthly by the drug worker. To prompt more frequently than that could be seen as 'nagging' and detrimental to the therapeutic alliance, in my opinion. As I see it, maintenance, stability, and employment are goals in themselves. Detox is a bonus. (But I accept that new targets may force me to review my stance). As I've already said, anyone expressing an interest in detoxing would be welcome to more frequent appointments, and some successfully detox while NAAF with minimal input from a drug worker. The clients are not unsupported, far from it; the level of support they receive is their choice.

I agree with other concerns about the team approach - my perception was that the NAAF clients who after a time approached me for more support did so because they'd met me on several occasions, I was still there, knew and remembered little bits about them, and they began to trust that I would continue to be there if they needed me. Many of the people who wished to be NAAFed in the first place had been in treatment for quite some time, and were fed up of their perception of having a different drug worker every five minutes (not their, my, or the GPs fault) and the easy format and infrequent but regularity of their reviews helped to reassure them that the system worked and they wouldn't have to recount their story all over again to a complete stranger. But I'm willing to be proved wrong and that a team drop-in could work.

In terms of caseload weighting, our service doesn't deal on a purely numbers basis. It's true that NAAF clients will usually be 1/2, 1/3 or perhaps even 1/4 of the work of a 'regular' client, but on the other hand, I can think of 'regular' clients who easily need double and triple the input of others - particularly true in the case of mental health or child protection concerns. We do operate a 'traffic lights' system to grade clients according to complexity and risk, and take this into account, but managers review workers' caseloads on an individual basis.

How the effects of the new Orange Guidelines will change the NAAF process (e.g. who completes the 3-monthly TOPS) has yet to be seen.

Sorry to ramble. Was probably more than two-penn'orth once all added up, but y'know... Hope that helps someone, anyway.

First of all thank you everyone for your comments on this. I really like the NAAF idea and will be in touch with Birmingham to arrange a visit. We have a really healthy shared care system here but the majority of clients seen in shared care have a drugs worker. Is this the norm?

Hi Campbell

yes that is the norm, actually the norm is usually that all clients have a drug worker, however I personally think that this can sometimes be a waste of resources.