Chapter 3: Evaluating the effective working of integrated addiction services
To evaluate the operational efficiency of integrated addiction services, the study focused on four areas:
1 . CATs working in partnership with health, social care and voluntary agencies
2. Access and referral routes into CATs
3. Information sharing, communication and assessment
4. General service development.
Working in partnership
Theme Context
CAT staff were asked to describe working in partnership with health, social and voluntary agencies; stakeholders were asked to describe working in partnership with drug, alcohol and complex psychiatric co-morbidity-related cases.
Addiction services in Glasgow prior to CATs
Different types of addiction services were provided by different health, social care and voluntary agencies. These services tended to be managed and co-ordinated at different places and across different organisational boundaries where partnership arrangements were significantly varied and diverse.
Analysis summary
- Partnership arrangements worked successfully where formally agreed links between CATs and stakeholder agencies were established. Collaboration tended to work less successfully when informal non-agreed links characterised partnership arrangements.
- Although continuation of pre- CAT links often meant that no new partnership links had developed with GCC social care agencies and CATs, this provided some degree of stability for CATs and GCC social care agencies during the transition period.
- New standardised templates or protocols implemented between CATs and partnership agencies were well received by CAT staff as they provided a source of reference and guidance for them during transition.
- During the first year, partnership arrangements with stakeholder agencies developed at a different pace between East and North East CATs. CAT staff and stakeholders attributed this to contrasting management approaches by both Team Leaders.
Implications for policy and practice
- Community Addiction Managers ( CAMs) should make the development of formally agreed links a priority.
- The development of partnership arrangements across multiple stakeholder agencies needs time and planning and should be phased in carefully.
- Promoting a new integrated service to stakeholder agencies should take place after the planning phase rather than before it.
- The development of partnership arrangements with stakeholder agencies should be prioritised. Implementing multiple partnerships simultaneously could create instability while accelerating the process could raise stakeholders' expectations and pressurise CAT staff during the teams' formative stages.
- Well-written, accessible and widely understood standardised templates would help to prevent CAT staff and stakeholders interpreting guidelines differently.
- Old protocols between partnership agencies could become outdated and potentially unworkable within a new service structure. These protocols need to be reviewed to prevent disputes arising.
- CAMS should begin to use a process of 'stakeholder management' within the new integrated structure. The increase in the number of stakeholders depending on CAT services - and on whom CATs depend - could give rise to a range of conflicting expectations.
- CAMS should attempt to work closely and in parallel with each other, developing partnership arrangements across a city or a local authority region. This would prevent inconsistency and disparity in service delivery.
- Stakeholder management could involve establishing formally agreed links
and ensuring that these continue to function effectively. Other issues
might include identifying where previously formally agreed links are 'at risk', addressing any problematic issues via a CAM network and preparing an advance contingency plan to mitigate the possible effect of organisational influences on current partnership arrangements.
Access & Referral Routes
Theme context
Prior to CATs introduction, stakeholders were asked where they previously referred drug, alcohol and complex psychiatric co-morbidity cases. The study examined referral patterns at 6 and at 12 months to determine whether they had changed or not. CAT staff were asked to describe the process that determined how referrals were managed within the CATs.
Access to addiction services in Glasgow prior to integrated addiction services
The main referral routes into pre- CAT addiction services varied in relation to the receipt and allocation of drug and alcohol referrals and many CAT staff and stakeholders saw these routes as convoluted. The majority of health and social care stakeholders did not always understand how the referral pathways for drug and alcohol services actually operated.
Analysis summary
- Access to CATs was found to be better than that to non-integrated services. This was attributed to the single point of access via the CATs, stakeholder co-operation and the introduction of liaison nurses or link workers.
- Divergent referral routes within the first 6 months slowly began to converge by 12 months as stakeholder agencies became more aware of the single point of access for CATs.
- Staff, stakeholders and service users reported that changes to access and the creation of new referral routes had produced new problems. For example:
- The 'buffering system' for drug service users created a new hurdle for clients as their referral was re-routed by nurses to social care workers. The 'pillar to post' effect, cited as a criticism of pre- CAT addiction services, had re-emerged.
- Some GPs found that advising patients to self-refer helped to ensure that 'new' patients could access treatment more quickly than 'current' service users within GP Shared Care clinics who had relapsed and required more support from the CAT. Referring these current patients back into CATs was not always successful as CAT staff argued that their clinics were full to capacity.
- The self-referral process was popular with stakeholders, but less so with CAT staff.
- Managing the referral process within the CATs was problematic, as no pre-determined criteria existed for how referrals should be distributed or allocated within both teams, and this issue eventually created tension amongst staff.
- Senior nursing and social care staff in both CATs were involved in deciding to whom referrals should be allocated but their perceptions of need often differed. They frequently used negotiation and bargaining to resolve allocation issues where there were 'grey areas'.
- GPs from addictions and mental health services were unclear where to refer complex psychiatric co-morbidity cases in an integrated addictions service. Many GPs were retaining the management of this client group, which might mean that some clients could be missing out on specialist intervention.
Implications for policy and practice
- Designing an Addictions Integrated Care Pathway ( ICP) from a single access point offers the benefits of clarity and flexibility to both stakeholders and service users.
- Co-operation and active intervention by pre- CAT addiction services should be sought during the early stages of a CAT implementation to address the issue of re-routing referrals.
- Stakeholders and referral agencies need to be made aware of changes to referral routes.
- A key aspect of CAM stakeholder management should include providing stakeholders with information about where stakeholders should send drug, alcohol and co-morbidity referrals within a new integrated service structure.
- Guidance and advice should be obtained from health, social care and voluntary services operating an open door policy to make sure that risk procedures within CATs are adequate.
- Allocation process times across cities or localities need to be aligned to prevent 'postcode lottery' issues emerging.
- The allocations process should attempt to move away from previously established practices and seek to encourage role development and integration of skills.
- Addictions ICPs need to base referral allocation decisions on client needs, rather than on capacity management issues or other factors.
- Addictions and mental health services need to give clear guidance to GPs about where to send complex psychiatric co-morbidity cases.
Information Sharing, Communication & Assessment
Theme Context
CAT staff and stakeholders were asked to describe the nature of information sharing processes for drug and alcohol addiction agencies prior to the introduction of CATs. At 6 and 12 months, they were asked to consider what had helped or hindered the information sharing in practice, and how language, terminology and the Single Shared Assessment had affected communication.
Information sharing and communication between addiction agencies before CATs were introduced
Information sharing and communication between health and social care addiction services were widely acknowledged by CAT staff as being ' very poor'. Separate information management systems and varying assessment procedures often tended to duplicate client information. All CAT staff were acutely aware of the frustration this caused to clients who might have to repeat their personal history during successive assessments.
There was also consensus and agreement amongst the stakeholder group that information was patchy between health, social care and voluntary agencies involved in addiction service provision. The statutory 'need to know' requirements of social care services, and adherence of health staff to professional guidelines regarding patient confidentiality was regarded as a constraint in sharing information across organisational boundaries.
Analysis summary
- Informal information sharing emerged as the main benefit of co-locating nurses and social care workers. For example, nurses and social care workers routinely asked each other to translate medical or social care terminology to provide clarity and prevent confusion during discussions about their clients.
- All staff in both CATs believed that the introduction of gaining informed written consent from clients for GCC and GGNHS to share information about them, if required, was a pivotal factor in enabling information to be shared with their social care colleagues.
- Stakeholders found that a single source of information coming from a joint management team worked more effectively than information from two or three management groups from both parent organisations.
- Communication between CAT staff was hindered by the non-reciprocal nature of the information-sharing process between health and social care information systems ( PIMS and Care First). Multiple recording systems were applied within CATs which either duplicated information or created a separate information system altogether. Nursing and social care staff were unable to share files electronically which meant that paper photocopying of the SSA and letters had become commonplace and client information was duplicated.
- CAT staff hostility towards the Single Shared Assessment ( SSA) lessened over time. This was because many staff actively became involved in finding solutions to making it more user friendly by adjusting its design. SSAIT personnel helped to achieve this by directly engaging with CAT staff, and attempting to resolve the problems regarding its use.
- The issue of what information was 'relevant' remained a source of debate between nursing and social care staff throughout the first year of CATs, where there was no consensus achieved between either group as to what constituted ' relevant' information.
Implications for policy and practice
- Shared working spaces, rather than separate facilities, can assist information sharing.
- Organisational Development practitioners can help to encourage information exchange between medical and social care workers, especially during the formative stages of team development.
- The introduction of the written consent procedure helps to address any ambiguity about sharing client information and develops confidence of CAT staff.
- An integrated joint management structure enables managers to deliver consistent messages to stakeholders about the strategic direction and operational developments of CATs on a regular basis.
- CATs need to make sure that flows of information being distributed and shared with the teams are consistent.
- Careful consideration needs to be given to the choice of information system within the CAT, to eliminate duplication of information and enable access by all staff. Factors that need to be taken into account include current IT infrastructures, systems' compatibility, information sharing protocols, training requirements, etc.
- Active consultation and involvement of CAT staff helps to improve SSA development.
- The SSA can only realise its potential if there is recognition and consensus among all CAT staff members about the information to be collected e.g. all parts of the SSA or just selected parts.
General Service Development
Theme Context
CAT staff and stakeholders were initially asked what signs might indicate that the CATs were proving to be effective in managing drug and alcohol addictions within the first 6-month period, and also where they perceived gaps in service provision within the new integrated service. At 6 and 12 months, they were asked to consider where CATs had made progress and where there remained perceived gaps in service provision.
Evaluation of service development
The evaluation process was initially expected to focus on service effectiveness and efficiency from service activity data sourced from the SSA and potentially from a joint information database. The CAT Service Specification also initially outlined that the evaluation would include clinical governance standards, minimal data sets, performance indicators, etc. In the event, reliable and accurate data from the SSA, a joint information database, integrated care pathways and clinical standards for the CATs could not be provided within the timescales set out for the evaluation. This meant that routine service activity or other quantitative measures could not be included as part of the report.
Measuring service developments was difficult when neither CAT staff nor stakeholders could conceive of what a new integrated addictions service was expected to deliver. Consequently, evidence given regarding general service development and perceived gaps was sometimes anecdotal.
Analysis Summary
Recognition of progress at 12 months
- Better alcohol service provision was cited as the area where CATs were widely believed to have made the biggest impact.
- Access to addiction services had improved for service users, particularly via the self-referral process.
- The range of services available to service users had improved.
- Joint working was taking place between CAT staff.
- Co-location had been achieved which improved communication, particularly with social care stakeholders.
- CATs were sensitive to needs of BME, gender, age, physical disability, and training and employment.
- Addiction services were now working from a psycho-social model.
- The addictions partnership was viewed as having developed more successfully than many stakeholders' previous experience of Joint Futures initiatives in Glasgow.
Perceived gaps in service provision at 12 months
- An exit strategy for methadone clients was still required.
- There was a lack of clarity on the Tier 4 interface regarding the management of psychiatric co-morbidity and alignment of Tier 4 services with CATs.
- More clarity was needed on the roles and responsibilities within the teams. Clarification was also needed on CATs' expectations of stakeholders.
- Service users, who were currently prescribed methadone but were also abusing alcohol, and the elderly population within GCC Adult Community Care Teams needed better, more targeted alcohol services.