NTA ISSUES GUIDE TO SUPPORT REHAB REFERRALS
After Addiction Today‘s highlighting of the lack of referrals to abstinence-based rehabs and consequent closures of these much-needed services, the National Treatment Agency for Substance Misuse issued Improving the quality and provision of Tier 4 interventions as part of client treatment journeys: A best practice guide.
Read the Centre for Policy Studies’ blog on the document here.
“Tier 4 service provision have not uniformly benefited from the improvement in capacity and quality experienced by community-based treatments since the launch of the first national Drug Strategy in 1998,” it recognises. “In fact, the lack of effective Tier 4 commissioning processes and structures in some areas has resulted in impeded growth and a failure to guarantee income streams.
“Improving Tier 4 provision is a key part of the National Treatment Agency’s (NTA) Treatment Effectiveness strategy. Tier 4 service provision can provide effective responses to drug misuse in treating people whose use has been long and heavy, and people with complex needs, and they can enable drug users to move towards long-term abstinence when and where appropriate. Inpatient service provision can also assess and stabilise chaotic clients and certain Tier 4 service provision may also have an important role to play in diverting individuals away from long-term substance misusing careers by intervening early
“The National institute for Health and Clinical Excellence highlighted the effectiveness of appropriate residential options.”
The guidance aims to address problems commonly reported in accessing and facilitating access to services.
DEFINITION OF TIER 4
Tier 4 comprises of two different but complementary categories of service provision as defined by Models of Care: inpatient treatment (IP) and residential rehabilitation (RR). Aftercare (AC) is a closely related category of service provision (see Annex 1-3 for definitions).
CHALLENGES IN COMMISSIONING TIER 4 SERVICES.
The following are the views of the NTA guidance.
During 2007-08, the NTA, in partnership with colleagues from the Department of Health and Home Office, worked to identify challenges facing those commissioning, providing and using Tier 4 service provision. Listed below are some of the issues that have been commonly found and which the guidance seeks to address.
a In a number of areas, there seems to be a lack of coordination and communication between joint commissioning groups at a strategic DAT partnership level, and social services community care managers at an operational level, with a large proportion of residential rehabilitation still being spot purchased rather than strategically commissioned. Despite the fact that there is general agreement that a collaborative approach between partnerships is likely to result in increased efficiency and improved quality, this is only practiced in a small number of localities
b Criteria for accessing services can vary significantly across the country, with very robust and clear policies in some areas and ones that are fairly obscure or sporadically adhered to in others. Criteria in a given area can also be clearer for one form of treatment (such as RR) compared to others (for example IP and AC)
c Individual Tier 4 services are often commissioned by a large number of DAT partnership areas. This results in different commissioning models (such as spot purchase vs. block contract) and service level agreements and monitoring requirements vary widely
d Some Tier 4 treatment providers have historically been poor at returning National Drug Treatment Monitoring System (NDTMS) data as required, making it difficult to monitor activity and outcomes in an objectively comparable way. These problems will be compounded by the introduction of the Treatment Outcomes Profile (TOP) (Marsden et al., 2007) as agencies failing to submit full NDTMS returns will not be able to evidence their contribution to effective client treatment journeys [Addiction Today comment: we emailed rehabs, which replied that they had complied but that their results were not being printed]
e There is a large degree of anecdotal evidence to suggest that much Tier 4 provision is purchased on a historical rather than evidenced basis, with some commissioners sometimes persisting with certain providers simply out of habit. This carries a number of risks, such as clients being referred to services that are unable to meet their needs, and that consequently Tier 4 provision will not represent value for money. [Addiction Today comment: as only 2-4% of patients get into rehab, this is hardly significant]
f Integrated care pathways between community drug treatment and residential service provision are sometimes poorly defined or adhered to
g In some areas of the country, there have been problems reported around a lack of coordinated post-discharge aftercare (for planned or unplanned discharges) when clients choose to remain in the areas where treatment services are located, as opposed to the areas from which they were resident prior to their referral being made. This can create significant pressure on local community drug providers and criminal justice agencies, as well as wraparound service provision (such as housing and health services)
h Commissioners and services have been slow to develop provision in a way that users and carers consistently say they want. Perhaps the best example of this is using Tier 4 as a last resort, rather than as a concerted attempt to achieve long-term abstinence earlier in a drug-using career. This has led to unsatisfactory outcomes for all involved. [Addiction Today comment: bravo! Excellently recognised]
i Some providers (especially non-NHS) report the need to chase up invoices, placing an unnecessary drain on staff resources. Conversely, there have been a number of instances recently where providers have taken referrals from a third party in the knowledge that individuals do not have their funding secured. They then invoice the client’s DAT partnership of residence retrospectively for service provision that the DAT did not commission
Due to the proportionately low numbers of individuals for whom DAT partnership areas will commission Tier 4 service provision, there is an inherent tension for individual DAT commissioners being able to devote adequate time to ensuring that they are commissioning the most appropriate and effective service provision
k A national review of inpatient service provision published by the NTA in 2005 concluded that a majority of inpatient assisted withdrawal (55 per cent) was still taking place in non-dedicated units. While it is understood that a small number of clients may need specialist mental health input at the same time as their drug treatment, there is some evidence that clients who are treated in specialist drug settings are more likely to have a positive long-term outcome.
l The Healthcare Commission and National Treatment Agency’s joint Improvement Review for 2006/07 looked at commissioning across partnerships. One of the questions asked was: “Were residential and in-patient services commissioned in line with national guidance?” . 48% of the answers to this question were scored as “weak”, indicating that this is an area that requires considerable and urgent attention for many partnerships. One of the main reasons that caused this was insufficient pathways in and out of Tier 4 service provision being specified in contracts.
You can read the full NTA guidance by clicking here.