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Transcript of Birmingham Total Place Pilot Drugs and Alcohol Customer Insight Steve Rose – Birmingham City...
Birmingham Total Place Pilot
Drugs and Alcohol Customer Insight
Steve Rose – Birmingham City Council
Simon Dickinson – Aperia
Neil Mackin - CACI
Total Place Birmingham
• One of 6 themes. Also: mental health, learning disabilities, guns and gangs, early intervention, total community, leadership & governance;
• Drugs and alcohol:– Drug recovery programme– Reducing alcohol-related hospital admissions– Alcohol availability and pricing– Customer insight
• The emerging threads
Birmingham Total Place
Moving beyond treatment to recovery:
“Unemployment, poverty, and homelessness make up the soup on which addiction and criminality feed. Work, prosperity and decent homes are aspirations
which encourage abstinence and honesty”
Paul Hayes, NTABirmingham, Sept. 2009
• Every £1 spent on treatment saves £9.50 in the criminal justice system
• Every £1 spent on recovery orientated treatment and community reintegration should save Birmingham considerably more
Drug Recovery Programme
Alcohol: reducing admissions• In Birmingham the equivalent of 1
hospital ward is occupied all year by patients suffering from alcohol specific conditions
• About 12 wards are taken up by patients with conditions which are linked to alcohol use to some degree
• One person was admitted 24 times in a year and cost £34,000 to treat
• Total hospital service cost in Birmingham is £5.7m
Steve Rose – Birmingham City Council
Simon Dickinson – Aperia
Neil Mackin - CACI
Customer Insight IDeA Funded Project Drugs and AlcoholCustomer Journey Maps and Recommended Pilots
HealthSubstance Services
Public Services
Emergency Services
Justice
Police
BCC
Drug & Alcohol Service
Providers
NHS Business Services
Hospitals
PCTs
GPs
Probation
Prison
DIP
Arrest
DAAT
Crime
Arrest Out of Hours Calls
Fire Incidents
DIP Referrals
Opinion Survey
Children (CareFirst
)
Housing (SX3)
WMPHO
BHWP
Needle Exchange Commissioning
Service Provider Commissioning
Case Manageme
nt Case Files
Prescribing Data
Aggregate Hospital Episodes
Monitoring NDTMS
Hospital Records
Case Files for Patients
A+E Admissions flagged for Substance
Offender Assessment
(OASys)
Accredited Programmes
(IAPS)
Prison Records
SPOC Call Centre
Revs / Bens (Northgate)
Adults (CareFirst
)
Public Health Mortality Files
Courts
Sentencing Records
Mental Health Trust
Drugs and Alcohol Data Map
HealthSubstance Services
Public Services
Emergency Services
Justice
Police
BCC
Drug & Alcohol Service
Providers
NHS Business Services
Hospitals
PCTs
GPs
Probation
Prison
DIP
Arrest
DAAT
Crime
Arrest Out of Hours Calls
Fire Incidents
DIP Referrals
Opinion Survey
Children (CareFirst
)
Housing (SX3)
WMPHO
BHWP
Needle Exchange Commissioning
Service Provider Commissioning
Case Manageme
nt Case Files
Prescribing Data
Aggregate Hospital Episodes
Monitoring NDTMS
Hospital Records
Case Files for Patients
A+E Admissions flagged for Substance
Offender Assessment
(OASys)
Accredited Programmes
(IAPS)
Prison Records
SPOC Call Centre
Revs / Bens (Northgate)
Adults (CareFirst
)
Public Health Mortality Files
Courts
Sentencing Records
Mental Health Trust
Drugs and Alcohol Data Map
The Consolidated Demand Index arising from Drugs Misuse:
1) DAAT Needle Exchange Volumes - Pharmacy Level aggregated to Ward
2) NHS Business Authority - Spend on prescriptions relating to Opiate Dependence
3) Police Data - Drug Possession Offenders
4) Probation Service OASys - Drug Offenders with Criminogenic Need
5) Demographic Propensity - derived from ACORN profile of Drug Offenders
Drugs - Demand
Consolidated Cost Index arising from Drugs Misuse:
1) Birmingham Opinion Suvey - Proportion who say that people using/dealing drugs in the local area is a big problem
2) Police Data - Instances of Drug Possession crime
3) HES Data - Inpatient Admissions for Drug Misuse
Drugs - Cost
The Consolidated Cost Index arising from Alcohol Misuse.
1) Birmingham Opinion Suvey - Proportion who say that people being drunk or rowdy in the local area is a big problem
2) Police Data - Instances of ARV crime (Alcohol Related Violence)
3) HES Data - Inpatient Admissions for Alcohol Attributable Reasons
Alcohol- Cost
Service Journey
DannySEGEMENT:- Drug AddictGENDER:- MaleAGE GROUP:- 25-40RELIGION:- n/aSTATUS:- SingleDEPENDANTS:- 1 child
DannySEGEMENT:- Drug AddictGENDER:- MaleAGE GROUP:- 25-40RELIGION:- n/aSTATUS:- SingleDEPENDANTS:- 1 child
How do we measure his outcomes?
How do we measure his outcomes?
Measures operations e.g. throughputNot have we achieved what the customer wants
Drug Workshop
• Hopes and Fears
• Their aggregated journeys
• What does the system look like
• What would they change
Circles of Need® - all content is © Aperia 2009
14
DRUGS
Not getting treatment
Wish my past would stop being brought up by the same people in social services (people can change). The past is what w e are trying to
move on from
JOBS
To get out of Birmingham and get a good life
Get a girlfriend & job with a good wage
Not becoming an addict again
To get a car
Drugs – Hopes and Fears
Not being funded to get a
tier 4 place
Not getting the help you need
To have enough money
To be abstinent from all
substances – legal and illegal
Of a lapse and taking an
overdose and dying from it
I am going to rehab. I just hope I can
complete and get to be drug free and start living my life
again
Of staying in Brum and leading the
same life as the last 20 years – and no
job
Treatment plan / centre not equipped for
my needs
Day care centre to run for 6 months –
it is only 3 now My past being constantly brought up
That things change in the right places
To fail and be on drugs for the rest
of my life
People to better understand
rehabilitated users
Family and friends finding out you are
on drugs
When someone is not prepared to
listen
To get my own flatTo regain contact
+ build relationships with
loved ones
To get fitter / more active
Being in the wrong place at wrong time and
end up using
Relapse into drug abuse
Help other people like me help themselves
To receive help + treatment from
services
Having too much money to spend on
wrong thing
To gain qualification through service
provider
To become valued member
of society
That I’ll be judged on my
past
Will never be able to get into a well paid job
againWont be able to gain employment because of my
past
DRUGS
Not getting treatment
Wish my past would stop being brought up by the same people in social services (people can change). The past is what w e are trying to
move on from
JOBS
To get out of Birmingham and get a good life
Get a girlfriend & job with a good wage
Not becoming an addict again
To get a car
Not being funded to get a
tier 4 place
Not getting the help you need
To have enough money
To be abstinent from all
substances – legal and illegal
Of a lapse and taking an
overdose and dying from it
I am going to rehab. I just hope I can
complete and get to be drug free and start living my life
again
Of staying in Brum and leading the
same life as the last 20 years – and no
job
Treatment plan / centre not equipped for
my needs
Day care centre to run for 6 months –
it is only 3 now My past being constantly brought up
That things change in the right places
To fail and be on drugs for the rest
of my life
People to better understand
rehabilitated users
Family and friends finding out you are
on drugs
When someone is not prepared to
listen
To get my own flatTo regain contact
+ build relationships with
loved ones
To get fitter / more active
Being in the wrong place at wrong time and
end up using
Relapse into drug abuse
Help other people like me help themselves
To receive help + treatment from
services
Having too much money to spend on
wrong thing
To gain qualification through service
provider
To become valued member
of society
That I’ll be judged on my
past
Will never be able to get into a well paid job
again
Wont be able to gain employment because of my
past
Hope I can get off drugs, but
fear I might not
Hope I can get off drugs, but
fear I might not
Fear that treatment wont
work for me
Fear that treatment wont
work for me
Hope I can get a job and a life
Hope I can get a job and a life
Past may stop me
getting a job
Past may stop me
getting a job
To be given a
chance to move on
To be given a
chance to move on
Break away from Birmingha
m
Break away from Birmingha
m
Give something
back
Give something
back
What others
think of me
What others
think of me
Drugs – Hopes and Fears
Parents send me to Brum – stayed
clean for 18 months
Several drugs services experiences in diff places – usually
positive
I self-referred to Azaadi and havent looked
back
Had very good care from mental health
CounsellorAzzadi has been a great help to
me
Pregnancy – went to GP
who referred me into
mother+baby
Forced into detox in Dublin (or kids taken
away)
Self-referral thru’ parents
DIP referral worked well for me
Mother+baby team helped me get clear before –
excellent dedication of team
DIP housing good – got my flat
Good relationship with my drug
worker
I got clean and felt positive and happy in prison for 8 months
Found 12 step was very beneficial –
9months gave me long enough to find a new
way to live without drugs
Referral by DIP was the start
DIP worker was brilliant
Phoenix futures, day structure – helped me with new skills+tools (but not
child friendly)
Safe proj and Anawim –
support me with everything
Mum passed away – self referral into
Azzadi
Addaction – very positive and good
follow-up
Threats again to take my kids
Day care services give u structure and
something to do
Methadone helps in that can survive without stealing
DRUGS –What helped?
Parents send me to Brum – stayed
clean for 18 months
Several drugs services experiences in diff places – usually
positive
I self-referred to Azaadi and havent looked
back
Had very good care from mental health
CounsellorAzzadi has been a great help to
me
Pregnancy – went to GP
who referred me into
mother+baby
Forced into detox in Dublin (or kids taken
away)
Self-referral thru’ parents
DIP referral worked well for me
Mother+baby team helped me get clear before –
excellent dedication of team
DIP housing good – got my flat
Good relationship with my drug
worker
I got clean and felt positive and happy in prison for 8 months
Found 12 step was very beneficial –
9months gave me long enough to find a new
way to live without drugs
Referral by DIP was the start
DIP worker was brilliant
Phoenix futures, day structure – helped me with new skills+tools (but not
child friendly)
Safe proj and Anawim –
support me with everything
Mum passed away – self referral into
Azzadi
Addaction – very positive and good
follow-up
Threats again to take my kids
Day care services give u structure and
something to do
Methadone helps in that can survive without stealing
Self-referral, parents played a
role (death or force)
12 step
Methadone
Individual key worker was the key
Its the service that counts
Clean in prison
Pregnancy and my parents
DRUGS –What helped?
Job Centre – didnt help
Summerhill terrace – RRAT dont treat
individual
Moving from JSA to ESA can be frustrating
Methadone
Came out of DIP – not
enough supportDIP East – no
follow up around relapse control
Government owned
services are less capable
Chest infection – got codeine and started to seek
drugs again
Waiting to go to Mum+Baby rehab
– delayed by child+fam
Doctors dont listen and seem to want control.
They are happy to keep you on script for as long
as possible
Getting back with other users
Aftercare coming out of prison was poor.
Worked hard for 3.5yrs, but no
support
Rehab was forced on
me – I wasn’t
ready for it
Doctors don’t want to cut down meths
Found other people using drugs (went
looking for them)
Waiting time after DIP is too
long
Other things other than methadone (morphine, pills/amps,
Df118s)Too much free money – unlikely to get job that
will pay enough to make it worthwhile
Give a straight detox in prison
Swansell – drug worker changed,
things went downhill
Prison was too easy – no deterrent, not enough help from
CARAT teamPrison – lack of help from drug
services, no rehab
Social services – tried to take kids and then dropped
me
No dry houses for women
Penalised if you have kids
Workers in the system get
moved around – not enough
professionalism
DRUGS – What hindered?
Job Centre – didnt help
Summerhill terrace – RRAT dont treat
individual
Moving from JSA to ESA can be frustrating
Methadone
Came out of DIP – not
enough supportDIP East – no follow up around relapse control
Government owned
services are less capable
Chest infection – got codeine and started to seek
drugs again
Waiting to go to Mum+Baby rehab
– delayed by child+fam
Doctors dont listen and seem to want control.
They are happy to keep you on script for as long
as possible
Getting back with other users
Rehab was forced on
me – I wasn’t
ready for it
Doctors don’t want to cut down meths
Found other people using drugs (went
looking for them)
Waiting time after DIP is too
long
Other things other than methadone (morphine, pills/amps,
Df118s)Too much free money – unlikely to get job that
will pay enough to make it worthwhile
Give a straight detox in prison
Swansell – drug worker changed,
things went downhill
Prison was too easy – no deterrent, not enough help from
CARAT teamPrison – lack of help from drug
services, no rehab
Social services – tried to take kids and then dropped
me
No dry houses for women
Penalised if you have kids
Workers in the system get
moved around – not enough
professionalism
Back with wrong people
Methadone and the way it is prescribed
DRUGS – What hindered?
Waiting for rehab – not enough space
Aftercare coming out of prison was poor.
Worked hard for 3.5yrs, but no
support
Flexibility in prison ?-
support after
More help coming out
of DIPWaiting –
rehab, mother/baby and after DIP
Changed
worker
Codeine for chest
Relats and frustrations
with benefits
Govt owned services less
good
What’s my
incentive?
RRAT not
individual
Not ready for
rehabSocial services and families
Alcohol Workshop
• Their aggregated journeys
• What does the system look like
• What would they change
21
Example Journey’s
Tightrope/balancing act
It’s a roll of the dice
Disaster awaits,perhaps feels inevitable
Example Journey’s
The clock is ticking……is time running out
No chances, ‘dark clouds’
There is a ‘system’but hard to break into itWith barriers along the way
Customer JourneysU
ps a
nd d
owns
of t
he c
usto
mer
exp
erie
nce
Key journey steps
Agency Touch-points
1991 2000 2008 2010
Suicide Attempt, A+E Admission
Relapsed upon release from hospital
Suicide Attempt, A+E Admission
Relapsed upon release from hospital
Suicide Attempt, A+E Admission; detoxed
Relapsed upon release from hospital
Medication treatment from GP
Off sick with depression
Started drinking JD with current partner who's alcohol dependant
Arrest and sent to hospital due to sickness and shakes
Forced 9 day Detox
Social Services Intervention around child
1st session; Search for activities (dance)
2nd session
Book appointment at GP for depression
Argument with Neighbours
Relapsed over weekend
Controlled drinking; Abuse from neighbours ongoing; Seeking help from Housing Seek additional
support for son
Arrange transfer meeting
Child in Need meeting with Social Worker
Depression
Unsure if employer support her
Depression – drink to cope with life Depression
Humiliated
Motivated to sort life out Worried
about son’s care
Hospital Hospital Hospital GP PoliceHospital
Alcohol Services
SocialServices
EducationHousing
38 yrs old. Female, Lives with 7yr son Older 18yr son who’s left home
2005
Drank with friends at home; family drink dependent
Caught in Abusive Relationship
Argument with rowdy neighbours who stop her sleeping after night shifts
Alcohol Services
SocialServices
Alcohol Services
SocialServices
Initial Views – the system• No clear shared understanding across the system of what
works and what doesn’t work
• No clear relationship between customer outcomes and service measurement / management
• No visibility of performance across the stakeholders
• and no Risks and benefits are not shared across partners
• Users believe there is a system, but providers / stakeholders do not perceive a system
• Very heavy skew towards tier 3 – only about 5% is spent on prevention
• Reliance upon fixed cost resource solutions, rather than networking, training and information
• No pathways
• Very service and contract placement led
25
Initial Views – customers• Using Advocate as a gateway to long-term recovery planning and
broader into public-service• More flexibility in service consumption – allowing users to design
recovery pathway– One size doesn’t fit all – More aggressive reduction from methadone (drug-free wings in
prisons?)– Encouraging more service user leadership and self support
(alcohol) • Time / target interventions around life events such as bereavement,
child-birth and family break-up• “Use my fear / pain”• Earlier referral into the system – by GPs, Adult Social Care, Housing• Use initial contacts to build relationship, rather than “fast-track” • Evidence base for controlled drinking
26
The True Cost of Drugs in Birmingham – Per Annum
Benefits Hospi
tal
Admiss
ions
Criminal Justice
SystemOther Spend
DAAT
£27.8m
£33m
£15m
£2.3m
£??m
Drug Treatment ProvisionPooled
Treatment
£13.1m
Drug Intervention Programme
£5.3m
Birmingham City Council
£1.3m
£3.7m
£1.08m
£3.4m £15.6m
£1.4m
•Police•Adult Social Services•GPs•Families•Schools•Mental Health Trust•Acute Trust•Probation•Prisons•Housing
•Single Point of Contact•DATUS Peer-led
Advocacy•DIP (BCC)
•DIP (ARW)
•Needle Exchange•Outreach•Inreach
•Addaction•DIP
CARAT•Midland
Heart•SADIE•KIKIT•BBV
•Community Outreach•GP Prescribing•CDT/DIP Prescribing•Swanswell•Turning Point•Safe project•EESPro•DRR•Mother & Baby
•Residential Rehab•Detox
•Structured day care
Professional
Self referra
l
Advisory
Tier 1 Tier 2 Tier 3 Tier 4
PCTs
£5.6m
Other
£357k
DoH Tier 4 Grant
£1.3m
Alcohol Treatment Provision
PCTs x 3
£3.8m
Safer Birmingham(ring fenced)
£250k
Birmingham City Council
£500k
£??? £170k £1.2m £2.4m £738k
•Social Service•GPs•HousingSPOC•YOT•Self Referred•Probation•Police•Community •Alcohol Team•Mental Health Trust•Acute Trust
•Freephone
•Pharmacy •Support Services•Alcohol Concern
•Self Help Sessions•(NACRO & RAPT)
•GP Screening
•Community Support Sessions
•BNE Erdington Outreach Worker
•Norman Imlah Centre•Arrest Referral Scheme
•Primary Care Services (alcohol
workers in GP clinics
•Alcohol workers in
hospital wards
•Aquarius•Birmingham & Solihull Mental Health Foundation Trust
•In-patient detox and
rehab services
Professional
Self
referral
Advisory
Tier 1 Tier 2 Tier 3 Tier 4
Summary Findings
• Limited insight into what works and what doesn’t work
• No shared visibility of performance
• Service / contract system, not focused on outcomes– Does system drive cyclical dependency? – less than 5% is
spent on prevention– We control the money…..No customer insight or control
over service consumption– Budgets don’t relate to need, drugs disproportionately
greater than alcohol funding
Drug/Alcohol assessment against TP principles
Shared clarity of objectives Health and Crime engaged Minimal input elsewhere
Performance measuring against genuine outcomes
Totally lacking
Pooled budgets For treatment Not for prevention
Shared responsibility and accountability for outcomes
NI indicators for LSP Limited cascade to drive outcomes
Joined-up commissioning of services For treatment Not for prevention
Services wrapped-around customer needs
Health management focused, not need or outcome driven
Sharing of information Parochial record keeping, is this in the customers’ best interests
Personalised for efficiency and effectiveness
Limited, predominantly one-size fits all
Key Recommendations – Drugs and Alcohol
• Make sustainable and incremental improvements in Drugs and Alcohol services, moving towards Total Place approach
– Establish outcome tracking and service demand– Drive transformation through a number of pilots– Undertake review and tightening of all contracts
and the DAAT operation
Future System?
Strategic assessme
nt of Service Demand
and Provision
Insight into
location, volumes
and people’s
wider
Prevention
Service Provision
Emerging Need
Severe or Acute
Need
Baseline Evidence Targeting MonitoringPilots
HealthSubstance Services
Public Services
Emergency Services
Justice
Police
BCC
Drug & Alcohol Service
Providers
NHS Business Services
Hospitals
PCTs
GPs
Probation
Prison
DIP
Arrest
DAAT
Crime
Arrest Out of Hours Calls
Fire Incidents
DIP Referrals
Opinion Survey
Children (CareFirst
)
Housing (SX3)
WMPHO
BHWP
Needle Exchange Commissioning
Service Provider Commissioning
Case Manageme
nt Case Files
Prescribing Data
Aggregate Hospital Episodes
Monitoring NDTMS
Hospital Records
Case Files for Patients
A+E Admissions flagged for Substance
Offender Assessment
(OASys)
Accredited Programmes
(IAPS)
Prison Records
SPOC Call Centre
Revs / Bens (Northgate)
Adults (CareFirst
)
Public Health Mortality Files
Courts
Sentencing Records
Mental Health Trust
Drugs and Alcohol Data Map
Advocates to Join Up Services toward Desired Outcomes
Keyworker as advocate to broadest
service offering
Increase Efficiency and Effectiveness of Service Delivery
Shorten treatment cycles by addressing contextual factors
Benefits
Effort
• Mis-users bounce around the public sector with great inefficiency and ineffectiveness• Sorting out their wider issues helps address their substance mis-use problem
Prevent Detect (incl. CJS) Treatment Positive Outcomes
Present
Future
Social Media Support Network
Benefits
Effort
Commissioning on Outcomese.g.
• Bonus for anniversary of positive outcomes• Reducing payments for very long term
clients
Social Media Self-HelpMutual support network for the alcohol mis-user community
Reduced dependency based service cost
Prevent Detect (incl. CJS) Treatment Positive Outcomes
• Alcohol misusers develop dependency on Tier 3 service consumption• Long term clients absorbing too much resource
Present
Future
Self Directed Personalised Support - drugs
• Failed treatment cycles• Lack of personalisation• Reduced ownership
Benefits
Effort
Increase ownership and reduce number of failed cycles
Self design packages of support
Prevent Detect (incl. CJS) Treatment Positive Outcomes
Present
Future
Service Redesign Pilots
• Advocates to Join Up Services toward Desired Outcomes
• Social Media Support Network - alcohol
• Self Directed Personalised Support - drugs
• Life Event Triggered Interventions around Customer Need
• Local Commissioning to Drive Service Efficiencies
• Local Culture Change to Drinking
Next Steps• Total Place Continues
– Progress ‘Birmingham Budget’– 5 principles
• Transformation• Prevention• Personalisation• Collaboration• Self sufficiency / reduced dependency
• Specific to Drugs and Alcohol– Drugs – “In Control” Manage change and design how to
make flexibility an intrinsic part of the ‘system’.– Alcohol – Social Media