NTA

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Commissioning quality in prescribing and care
planning
Dr Emily Finch, Clinical Team Leader, Diane
French, National Programme Lead, Standards and
Inspection
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Findings - Overall Score
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Community Prescribing
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Community Prescribing - commissioning
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C1 Commissioning

• Community prescribing services are commissioned
  in line with models of care and clinical
  guidelines
• Self assessment of service level agreement
• Specified template of best practice (10 spot
  check)
• Core items are
• Definition of service
• Aims and objectives
• Eligibility criteria
• Description of service
• Priority groups
• Exclusions and contraindication
• Description of services
• Policies and protocols
• Level 2 3 basic core items, Level 3 all items

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Community Prescribing - access
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C2 Access

• Service users have prompt, equitable and flexible
  access to community prescribing services
• How long do people have to wait to access
  community prescribing?
• Can people who use services access primary care
  treatment? gt30 of GPs in some sort of shared
  care
• Flexible opening hours (aggregated to DAT level)
• Findings from user satisfaction which are
  relevant
• - longer waits associated with less
  satisfaction
• Research evidence does not show a clear
  association with outcome

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Community Prescribing assessment and care
planning
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C3 Assessment and care planning

• Personalised care plan that incorporates
  comprehensive assessment
• Are the tools comprehensive?
• Is there a comprehensive risk assessment
• Relates to triage, comprehensive assessment care
  plans and risk assessment tools submitted by
  agencies
• Scored on a proforma
• Done for prescribing services in the DAT only
• User satisfaction findings
• - 59.4 had a care plan
• - Review in last 3 months are more satisfied
• - No care plan are least satisfied

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For exampleRisk assessment scoring template
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Community Prescribing prescribing practice
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C4 Prescribing Practice

• Prescribing practice is in line with Models of
  care and the Clinical Guidelines
• Is the agency's prescribing policy in line with
  MOC and CG?
• Experience of service users
• Title of completed audits by SM service or trust
  in last 18 months
• Looking for outliers and inflexible policies
• User satisfaction
• 50.4 receiving 57.5mg
• 35.3 gt60mg
• Prescribing audit
• Mean dose nationally 56.7mg methadone
• 8.9mg buprenorphine
• NICE technology appraisals (methadone and
  buprenorphine for maintenance and naltrexone for
  relapse prevention) and guidance awaited on
  detoxification and psychological interventions
• Clinical guidelines revision in progress
• Role of low doses uncertain

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Prescribing audit

• What is the mean daily dose for methadone?
• Range of doses prescribed
• Range of supervised consumption for Methadone
  undertaken within the first 12 weeks
• Range of supervised consumption for Methadone
  undertaken after the first 12 weeks
• Range of methadone treatment options (i.e.
  tablets/ oral methadone/ mixture) offered
• Range of buprenorphine doses prescribed
• Range of supervised consumption for Buprenorphine
  undertaken within the first 12 weeks
• Range of supervised consumption for Buprenorphine
  undertaken after the first 12 weeks

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For examplePrescribing audit scoring

• If 60 or more of doses fell within 1-30mg and
  31-60mg or alternatively 60 fell within 91-120mg
  and 121 this raised concerns about the range of
  prescribing offered and therefore scored a one,
  anything else scores a two.

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Community Prescribing controlled drugs
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C5 Controlled drugs

• Community prescribing services have procedures in
  place to ensure controlled drugs are administered
  in accordance with best practice
• Following procedures in place
• adverse incidents procedure
• prescribing policy
• prescribing review procedure
• complaints procedure/ practice protocols
• meetings with pharmacists to discuss issues (e.g.
  adverse incidents)
• risk assessment protocols (e.g. in the case of
  overdose)
• formal dose titration process for methadone
• formal dose titration process for buprenorphine
• How many untoward incident reports have been
  completed in last 12 months?
• Against national benchmark
• Do staff feel able to report such incidents?
• Staff feedback in NHS staff survey

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C5 Controlled drugs issues?

• User satisfaction
• 73.4 supervised methadone 5-7 days per week
• 65.6 supervised buprenorphine 5-7 days per week
• Not associated with satisfaction
• Use of NHS staff survey
• Pharmacy guidance clarifies some issues

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Community Prescribing staff competencies
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C6 Staff competencies

• Community prescribing services are delivered by
  competent practitioners who are appropriately
  trained and supervised
• Covers range of staff
• Focus on vacancies and temporary staff as
  reported by services
• Use of NHS staff survey
• User survey
• Keyworkers most likely to treat them with respect
• Pharmacy staff and other users least likely

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Staff competencies - questions

• Is the service delivered by experienced and
  trained staff?
• What is the prescribing service(s) rate of
  vacancies by staff group?
• What is the prescribing service(s) rate of
  temporary staff by staff group?
• Do you have a case load management system (case
  load weighting system)?
• What is the level of staff satisfaction with
  their job and the organisation?
• Do staff report adequate support, training,
  supervision and appraisal mechanisms?
• What is the experience of service users being
  respected by staff?

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Care planning Conclusions

• Each criteria is supported by indicators of good
  practice only
• Overall picture more important than individual
  areas
• Acknowledge areas of uncertainty
• Encourage services and partnerships to continue
  to examine their practice
• Encourage services to learn from and repeat audits

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Criteria for Care planning and Care Co-ordination

• Criterion 7 Users are integrated partners in
  treatment planning and are fully informed about
  treatment options
• Criterion 8 Users have rapid, equitable and
  flexible access to range of drug treatment
• Criterion 9 Users have personalised care plan
  including comprehensive assessment of needs
• Criterion 10 Pathways through treatment are
  clear, co-ordinated and continuous
• Criterion 11 Services operate systems to
  minimise client DNA/drop-out rates and to support
  client retention

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Care Planning and Care Co-ordination
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Users are partners

• Do provider agencies support service user
  involvement and provide information about the
  range of services available?
• financial support to service users participating
  in service delivery and monitoring
• local service specific user forums
• access to strategic planning groups for service
  users
• training and/or mentoring for service users to
  enable participation in service planning and
  monitoring
• Are service users involved in treatment planning
  and delivery at strategic / drug action team
  level? (Tx Plan)
• What is the experience of service users of having
  their views taken into account and involvement in
  care planning? (service user feedback)

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Criteria 7 Question 1
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Criteria 7 Question 2
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Criteria 7 Question 3
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Care Planning and Care Co-ordination
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Access

• How long do people have to wait for access to
  drug treatment service modalities on average?
  (weak if two or more modalities not meeting
  targets)
• Is the full range of treatment options available,
  as described in Models of Care? (self assessments
  of contracts)
• Is the full range of treatment options, as
  described in Models of Care accessible to the
  whole drug action team population? (Tx plan and
  service user feedback)

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Criteria 8 Question 1
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Criteria 8 Question 2
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Criteria 8 Question 3
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Care Planning and Care Co-ordination
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Assessment and care plans

• Are assessment tools and care plans comprehensive
  covering the full range of needs based on
  measurable goals?
• Is there a comprehensive risk assessment as part
  of the assessment process?
• Not as good in all tier 3 as in prescribing

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Criteria 9 Question 1
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Criteria 9 Question 2
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Care Planning and Care Co-ordination
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Pathways

• Do formal partnership agreements exist for the
  following interagency policies?
• Information Sharing Policy
• Child Protection Policy
• Care Coordination Policy
• What is the service user experience of referrals
  to Tier 1 support services?
• Are there clear and appropriate protocols for
  care planning and coordination across agencies?
  (Tx plan)
• Care plans are reviewed regularly? (first 3
  months and after 3 months)

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Criteria 10 Question 1
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Criteria 10 Question 2
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Criteria 10 Question 3
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Criteria 10 Question 4
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Care Planning and Care Co-ordination
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Drop out of system

• Retention
• Completion

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Criteria 11 Question 1
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Criteria 11 Question 2
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Care planning

• I have a
• cunning
• plan
• (bbc.co.uk)

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Care planning and the treatment journey

• Not discrete stages acknowledged overlap
• Can assist in organising care to meet clients
  needs

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Things we know about care planning

• Providers are already doing it
• Some do not do it well, consistently enough or
  cannot demonstrate it
• Core principle in mental health care (i.e. CPA)
  although there are important differences
• Many clients are not involved in their care plans
• Starting point concentrate on implementing
  current systems better vs designing new systems
• Care planning practice guide to provides guidance

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Care Planning Principles 1

• Underpinned by keyworking
• May identify need for coordination of care
• Assessment process identifies needs ?
• Needs are translated into goals ?
• Interventions are designed to achieve those goals
• Identify those responsible for delivering an
  intervention (including the service user)
• Identify review date

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Care Planning Principles 2

• Goal setting
• Incremental changes
• Realistic goals (SMART)
• Limited number of goals

• Care planning domains
• Drug and alcohol use
• Physical psychological health
• Social functioning
• Criminal involvement

• Risk assessment is integral and continuing

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Care Planning Principles 3

• Clear responsibility may be more than one
  person / agency delivering services
• Simple and easy to communicate to others
• Collaborative process with client
• Review minimum yearly usually 3 monthly.
  Opportunistic reviews if problems arise or
  successes come early

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Care plan record

• Practice guide provides contents checklist
• Set minimum standards for care planning
• Services may have their own if they already meet
  the minimum standards no need to change
• Clarity to ensure principle of informed consent
  
• Must be understood by the service user
• No more than a single side of A4
• Compatibility e.g. EMIS template in primary
  care, other record / information management
  systems

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Outcome monitoring

• Use of validated tools where available e.g. MAP -
  Maudsley Addiction Profile (cf NTORS)
• Specific tools for specific problems e.g. Beck
  Depression Inventory
• May be difficult to administer routinely useful
  for short term monitoring or research
• Negotiate follow up outcome monitoring
  strategies with commissioners, University
  partners etc

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Audit processes performance management

• Subject complete care planning process or
  specific elements of it to the audit cycle
• Feedback to inform team study days and case
  discussions
• Case allocation, performance management and
  supervision
• Service Level Agreements include a requirement to
  care plan

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And Finally

• Active care planning as a means to improve
  practice
• Improving communication between service providers
• Supporting service users to identify and attain
  appropriate treatment goals
• Set standards across sector equitable treatment
• Individualised comprehensive treatment services
• Enhancing service users active involvement in
  their own care literally empowering them