Afternoon all,

I've recently got the exciting opportunity to start a shared care service in Suffolk so I'm sure this will be the first of many queries!!!!!

My DAAT coordinator has posed the following question:

What kind of throughput do you envisage for the service or what contingency do you have in place should the service reach capacity and still have referrals arriving?

My target in the first year is 200 clients into shared care. We are covering the whole of Suffolk and I have myself and 2 full time equivalent workers.

Any help on this topic will be greatly received!!!

Hi Daniel
This does sound very exciting and I wish you every success. My first thought on reading this is to wonder if between the three of you you intend to personally keywork all of these clients. If so, you will have about 66 clients each, and if you see them fortnightly you will need to see 33 a week, 6-7 a day. You may be able to recruit enough clients to outlying towns to spend a whole day seeing them which will cut down on travel. Alternatively you might see them monthly with perhaps the GPs seeing them alternate fortinghts. (this might be one measure you could suggest to the commissioner as a way of easing the possible capacity saturation scenario he has posed)
My second thought is: what is the baseline, is there any shared care existing, is there a contract and pay agreed? Are there GPs who are known to prescribe? Have enough or indeed any of the GPs got RCGP certificate part 1? If not, recruitment and training time needs to be factored in. Your regional RCGP lead (contact the RCGP substance misuse unit) may be able to help, as might the clinical lead doctor for your service.

here is a link to a reply I made to a colleague of yours from Suffolk about a week ago, called Sam. I basically outlined some areas you might need to look at and offered our support should you need it

Thanks for the reply. Do you work nights or are the forums a useful cure for insomina!?!

I am proposing a keyworking system but not care coordinator. As such, in theory(!), the clients referred into the service will have come from secondary care, be of a stable nature and without complex needs (i.e. housing, harm reduction, benfits delivered on). Then (correct me if I'm wrong) NTA states they only require being seen every three months, which the GP will be doing at least that much. The team will then check with the GP regularly if things are going well and offer increased support if problems are experienced. Does anyone else offer this system?

For GPs with a larger amount of clients (say 6+), as you suggested, I'm proposing we run clinics with the practice to ease the workload.

I'm interested to see if any other services work this way. And if so how it affects their capacity, do they keep taking referrals and support the GPs rather than closely supporting the clients. Does anyone put a time limit on how long someone stays in the service (not my ideal but if purely looking at cost effectiveness/avoiding bottleneck it maybe that of a comissioner).

We are forunate that must of the second part of your response I can answer yes to and we run the RCGP training locally. Thanks for taking the time to answer

http://smmgp.groupee.net/eve/forums/a/tpc/f/1064030241/...391033352#1391033352

sorry heres the link

Clients don't always stay stable and with no complex needs! I have lots that should be in secondary care but manage them in primary care quite effectively most of the time. Even if they are very stable I wouldn't see them less than monthly.

Hi again Daniel
I think there are several points that need addressing here - the main guidance for this is the new clinical guidelines which contain a whole chapter on psychosocial interventions and keyworking. A few brief points:
1. There is now no major distinction between care coordination and keyworking.
2. GPs can be keyworkers but they need to build a therapeutic alliance with the client and have thetime and competencies to perform the full range of keyworking functions (as detailed at great length in chapter 4)
3. Whilst the guidelines are not prescriptive as to frequency of keyworking sessions, they do specify that they should be regular.

I think it is also relevant that the NTA business plan, emphasises the need for afacilitated treatment journey and exit.

Lastly and MOST IMPORTANTLY it is absolutely unacceptable from NTA or CG point of view to time-limit treatment - it takes as long it takes, hence the need for skilled keyworking to help people move through treatment and not become stuck (which none of us, patients, relatives, providers or commissioners want). The days of a cup of tea and chat about the football style of keyworking are gone - this is a targeted care-planned and skilled intervention.
You must read them - they're on the front page of this site. Then you must tell us what you think of them!!
hope this helps

I'd just like to back up what Susi was saying. Time limits were used in the past (often for exactly the reasons you give). However they are now considered universally to be bad practice due to the evidence that the longer people are retained in treatment the better their outcomes. Also the fact that discharging someone whaent hey are not ready will cause major health and social damage and is possibly worse than not having treated them at all, in particular the hightened risk of death.

I agree with all that susi, jim and beverley have said.

Everyone has, or is entitled to a GP, and 86% (or maybe 97%) people with problems with substance use are best cared for within their own properly trained and resourced primary care team, most without ever going near a specialist service.

To enable this, a drug worker needs to be attached to each primary care team so that the GP and wider team get to know them and the drug worker can feel part of the wider team including health vistors, midwives, all the nurses, counsellors, receptionists etc.

So you need most of the area's GPs trained and paid to provide the service,(via a DES or a LES, while these still exist) with GP mentors they can ring if there are any complex problems, and pharmacies accessible to all, paid and (importantly) trained to offer confidential supervised consumption, advice and monitoring of wellbeing, Drug workers centrally trained and supported, but embedded within each practice for 1 or more sessions each week.

GPs can offer the biological part of the assessment and prescribing process, and are well used to chronic disease management but we are too expensive and sparse a resource to be able to give more than brief regular GP type appointments to such a large population, so as Susi points out, the drug workers need to spend longer hours with people offering the kind of structured psychosocial interventions which are shown (at least in american research ) to make the difference.

In this area, some patients within a GP surgery will see mainly the drug worker (if they have complex psychosoial problems.. as beverley says apparant stability is very changeable). This group may see the GP less frequently, but at a minimum every 13 weeks for review. Other patient s may not need or want much drug worker intervention at present, and may see the drug worker only twice a year (minimum) for care plan review, and see only the GP in between.

One of the many advantages of primary care is that we don't "discharge" anybody, and are well able to support people with this kind of chronic relapsing problem, throughout however long it takes, and also for the rest of their lives afterwards. Of course at some point if drug free they may not longer need to see the drug workers, but may still like to say hello when passing them in the corridor, for the mutual benefit of admiring their excellent progress.

In this area the drug workers sessions have been enlivened , structured and informed over the last year by using a local version of the initially baffling, but soon strangely simple nd effective "Node link mapping" worksheets developed in texas (and available online) :

http://www.ibr.tcu.edu/pubs/trtmanual/manuals.html#mapping
for more info about this, you could ring Birmingham's DAT and speak to Ed Day, or to David Best.

Good luck.

Also for "GP" in the above, you could of course read nurse prescriber or phamacist prescriber, both of who can be embedded in a primary care team.. at present still working with these rather irritating clinical management plans, in cahoots with a GP colleague, but soon to be able to prescribe for substance misuse independantly we are told. Patients still also need a drug worker, to avoid the prescribing in isolation trap.

quote:

vel

Thanks for the replies on this subject and I agree wholeheartedly on the subject of time-limited treatment.

However, after reading the new Clinical Guidelines I do have some feelings on the keyworking/care coordinating issue. Is the problem that Models Of Care has not clearly stated the system we should work to? Are we undertaking the Care Programme Approach (CPA) where care coordinators coordinate multi-agency input, required for clients with complex needs, where as keyworkers deliver one area of the care package. If so, for clients whose only area of need is a long term prescription, does this require care coordination? Has care coordination only been adopted because many providers are mental health trusts and in fact it is not suitable for substance misuse?

I consider other conditions to be similar to substance misuse i.e. diabetes, mental health, chronic pain, where clients do not always stay stable and the symptoms can have a chronic relapsing nature. For example, if a person with a bi-polar condition has been through secondary m.h. services and is now stable on medication, do we expect that person to remain care coordinated by a CPN for numerous years? Surely the GP manages the condition and then refers back if there is concern for a manifestation of symptoms? The GP is not the keyworker/care coordinator for that person when they are managed in primary care. We seem to be suggesting the opposite for substance misuse and I do feel concerned about reaching capacity and bottlenecking the treatment system.

I do have sympathy with GPs who have been left isolated managing people with mental health issues who sit between moderate and severe mental ill health and I am aware that some Trusts are employing link workers with surgeries to support the practices. Is this not more ideal for substance misuse?

Of course this is on individual need but I feel concerned my team will be swamped with meeting the Guidelines when actually a better job could be done concentrating on supporting the GPs under shared care (and clients when need is identified) and increasing the throughput from secondary care to primary care so that secondary care can free up spaces for clients with complex needs who are doing the most amount of harm to themselves, carers and, arguably, society.

Wow what a rant!!! Any thoughts?

Daniel, the concept of a Shared care service only for stable well sorted clients is one that my local CDT have embraced to exclusion of all else. Rather embarrasing as I am the Shared Care GP lead. In April this year, just before the RCGP National Conference, my team drew up their list of exclusions. The RCGP conference presented the list of inclusions early on the first day. The two lists matched. I explained that Shared Care can and shuld be more than this, at least as far as the RCGP is concerned. Isn't the way forwards for the majority of Drug Misusers to be provided with their treatment in Primary care? The adjacent "CDT" is in fact totally Shared Care as they do not have a central CDT at all. It works. However, you have to provide as much support as the client needs, rather than a minimal down graded service. Shared Care shouldn't equal second rate care due to lack of Drug worker time. I feel my Shared Care service is poor, with case loads of 60-70 clients and minimal drug worker input.
Back in the 1980's to early '90s, Drug Misuse Management was often done with low levels of input, basically just a script. the outcomes were poor. I wonder how your clients would fare if they were only seeing a drug worker every 3 months? Would their stability and their ability to complete treatment be impaired?
Feel free to contact me and perhaps come up to see the two contrasting services. or just have a day in the Lakes!

From Clinical Guidelines 2007 section 4.2.1 p35:
Keyworking is a basic delivery mechanism for a
range of psychosocial components including:

This message has been edited. Last edited by: susi,

Thanks Rob for the word of warning. I'm in quite a fortunate position in that our service is under the PCT umbrella where as our drug services are a secondary trust. I'm hoping this gives me the freedom/flexiblility to develop a service as I see it best suiting the needs of the clients within it not to fit in with the treatment system thats in place.

I'm currently of the opinion that this will currently suit the end of treatment, community reintegration stable clients because it a) contributes to freeing up the treatment system b) demonstrates progression to the person/family and c) gives GPs with little experience of substance misuse the opportunity to realise that clients are not going to steal our script pads, deal drugs to people attending the flu jab clinic (!!).

However, as confidence grows, I would like to see the service develop into the adjacent system that you were speaking of.

A day in the Lakes would be fantastic, however currently I'm spending every waking minute writing a service specification. Would you (or anyone else) happen to have any clinical guidance/handbooks on either or both of the services (other than on this website)? If you could email them to me I would be grateful to compare how they are written. daniel.chapelle@suffolkpct.nhs.uk .

Many thanks for the posting and will bear your experiences (and the offer of a visit) in mind.

This message has been edited. Last edited by: Daniel Chapelle,

apologies for my last post I appear to have deleted most of it when i edited it - a pity as it was by far the best posting I've ever done, and was about to revolutionaise drug treatment as we know it....

Ah but seriously, Daniel, must try to summarise what i was trying to say then as your last but one post brfought up some important issues - will be v brief as its late but do ask more qs to get clarification
a) care coordination in substance misuse is seen as a function not a person. It is needed for patients who are recieving care from more than one agency. It is usually done by the keyworker
b) Substnce misuse, unlike most other chroic diseases has the potential for (almost) complete resolution. There is also a huge will in society to see this, witness the abstinence vs harm minimisation debate that has been raised by the media in the last few days, flying in the face of the evidence though this may be. It is therefore important for us who are delivering treatment to ensure that the door for treatment exit is always kept open for all our clients. There is evidence to show that frequency of psychosocial interventions is proportional to outcomes, so whilever there are still unmet goals in their care plan, clients should continue to recieve an adequate frequenmcy of keyworking.
c) prevention of GP isolation has been an imperative since the 1999 guildeines. It is about safety for patients and doctors, as there was a spate of clients dying of OD after GPs initiated methadone, and GPs being threatened with being struck off. There are lots of other reasons for prevention of isloation but i won't go on....
d) No team should be swamped by the guidelines, commissioners should commission sfficient services to meet the assessed clinical need in accordance with national guidance.
e) primary care does a great job of 'unblocking' secondary care places as you describe, but can of course become saturated itself if pateints never exit. If primary care capacity gets saturated consider:
maximising efficint use of kw time by facilitating patients from other practices to be seen at shared care surgeries
recruiting more practices
use of non medical prescribers
probably lots more but can't think of them now!

Thanks Susi for the response. I appreciate the comments you have made and will take them onboard.

Client need and safe prescribing will drive how the service develops.

I'm looking forward to your lost email that will revolutionise treatment!!

*pumps fist* "UP THE REVOLUTION"