Integrated Care for drug users: Principles and practice: page 13

Integrated Care for drug users: Principles and practice

ANNEX 3A
A THREE-STAGE APPROACH TO ADDRESSING WAITING TIMES

This Annex sets out a three-stage approach to addressing waiting times:

Minimising Waiting Times (Stage 1) focuses on the development of systems to ensure that clients are directed to the most appropriate services as quickly and effectively as possible. It involves streamlining administrative systems to maximise the use of practitioners' time.
Managing Waiting Lists (Stage 2) comes into effect when clients are having to wait for an unacceptable length of time for care and treatment. This stage requires that cases be prioritised and that steps are taken to ensure that the health and well-being of clients waiting for services is not put at risk.
Developing Contingency Plans (Stage 3) would be initiated when the ability of the service provider(s) to see new referrals is compromised as a result of waiting times.

Included at each Stage are key action points at client, agency/service provider and integrated services level, adapted from the National Treatment Agency paper "Making the System Work" (NTA 2002).

This Annex also sets out information on the monitoring of waiting times and details of current waiting times research.

1. Minimising Waiting Times

Traditional approaches to improving access to services and reducing waiting times have focused on creating additional capacity within agencies. However, there is increasing awareness and acceptance of the role of service planners and referring partners in managing demand for services and improving the overall experience of the integrated care process.

From the information collected we have identified the following approaches to minimising waiting times:

joint planning
improving referral patterns
appointments and bookings
re-assessment
triage and re-distribution
communicating good practice
managing resources to meet need

Joint planning

It is increasingly clear that effective management of capacity and demand must be carried out as a joint responsibility between services: for example, between primary and secondary care in health and across services such as health, social work and housing. As is often said "If we always do what we've always done we'll always get what we've always got" (NHS Modernisation Agency, Type 3). In order to reduce delays and improve access, systems need to be re-designed to improve waiting times.

In the health field, there is increasing awareness and acceptance of the role of primary care in managing demand for secondary care services. The work of the National Primary Care Development Team (NHS Modernisation Agency 2002, Type 3) goes one step further and introduces the concept of primary care managing a specified level of capacity of secondary care for their local population. This involves establishing a system of capacity and demand management which forms the central core of a range of activities that can be undertaken jointly between primary care and secondary care, to improve access to routine services.

Improve referral patterns

Statistics from the Scottish Drug Misuse Database, 2000/01, show the most common sources of referral to drug services to be GP and self (41% and 34% respectively).

The recent developments within the criminal justice system: Drug Treatment and Testing Orders, drug courts, arrest referral schemes and the Scottish Prison Service transitional care arrangements will have to be reflected in agreements at local level on the criteria and processes of referral. This should ensure:

access to the right service
core information for the assessment process

There are, at present, no specific questions on referrals from arrest referral schemes, DTTOs etc. on the Scottish Drug Misuse Database. It would, however, be possible to adapt the system to pick up this additional detail in future.

Service providers require a shared knowledge of where to refer someone on to, depending on their presenting need(s). Individuals wishing to refer themselves to a particular service will require up-to-date knowledge of what services exist in their locality and what the remit for a service is. This information will assist the individual to identify and approach the most appropriate service provider for them.

The referral process should promote accessibility to services at a time when they are needed. It depends on joined-up working between agencies. The process would be aided by:

a directory of local services
a referral form designed around the core data sets outlined in Chapter 4
clear sign-posting information on services including 'Client Information Leaflets' and active outreach work

Appointments and bookings

Service providers and service users have stated that appointment systems are not always designed to reflect the needs and lifestyle of the clients who have serious drug misuse problems (EIU consultation workshops 2001, Type 5; SDF 2002, Type 4). There may also be problems with managing non-attendance in ways that increase the waiting times for others if the appointment cannot be allocated to another client. Service providers suggested that the provision of a number of community-based satellite points, with opening hours that reflect the needs of the client group rather than the needs of the service, would reduce non-attendance (EIU Consultation Workshops 2001, Type 5).

Auditing non-attendance patterns at service provider level can help to identify indicators associated with non-attendance. A study by North and East Devon Health Authority on patient, hospital, and general practitioner characteristics associated with non-attendance examined a cohort of 1972 referrals from 26 general practitioners, with complete follow-up (Hamilton 2000, Type 3). Five factors were found to be significantly associated with non-attendance: male sex; younger age; longer interval between referral and appointment; higher Jarman (Deprivation indicator) score and patients of high-referring GPs. Development of strategies to reduce non-attendance is possible using these results.

Re-assessment

The amount of time involved in re-collecting information when clients re-present at services could be reduced by ensuring that assessment processes allow for an update of information, to build on existing knowledge rather than a new assessment to be carried out (see Chapter 4 on Assessment for further information).

Triage and re-distribution

Following assessment it may be beneficial to consider how best the resources of an agency (or agencies) involved in an integrated care network can be employed in delivering the care required for the individual. Rather than "lining clients up" to see a particular person or service provider, the needs of the client may well be met through employing a triage and re-distribution system. Factors to consider in triage and re-distribution include:

the demand for a service
the number of service providers who could provide this service
the current capacity of these service providers
the preferences of the individual

Communicating good practice

There may be useful approaches to the management of waiting times in other parts of Scotland and from other sectors. In the NHS, later in the year, an on-line good practice guide will showcase examples of good practice (see 'National Waiting Times Initiative', in Section 4. 'Monitoring Waiting Times'). "The database will enable the best possible use of capacity across the NHS in Scotland, help identify and shift bottlenecks and should even out the inconsistencies in waiting times across Scotland" (Mr Malcolm Chisholm MSP, Minister for Health & Community Care).

Managing resources to meet need

Chapter 5 on Planning and Delivery of Care highlights the need for integrated planning of care between service providers in order to ensure that services are in place when the individual needs them. This should ensure that clients waiting to move on to the next phase of their care are not delayed by administrative or resource difficulties. Often this situation has arisen in the past where there has been limited provision of substitute prescribing services outwith the specialist drug services. These service providers become log-jammed and unable to take new referrals.

DATs and partner agencies should develop local protocols aimed at ensuring a seamless transfer of care between service providers. At a service or locality level this will require agreement on:

referral procedures of participating service providers
discharge protocols, including those for non-attendance, which recognise the implications for other agencies
joint transfer planning arrangements.

Key Action Points for Minimising Waiting Times - at Client, Agency/service provider and Integrated services level

Level

Action Point

Client

Produce individual care plans with goals
Service providers should:

produce individual care plans for, and with, each client. Plans should include and be based on clear and achievable short, medium and longer term goals
review care plans in partnership with clients on a regular basis
develop joint care plans with shared care providers, where involved. All providers should agree and review the care plan with the client.

Develop discharge plans
Providers should include a provisional discharge date in the initial care plan, which reflects the client's goals

Develop clear protocols for clients who have defaulted
Service providers should:

develop clear protocols for early discharge. These should contain possible interim steps to help clients resolve difficulties where possible, and be implemented fairly and consistently
involve any other agency, which is sharing the client's care, in the decision making process e.g. a specialist mental heath service sharing the care of a client with dual diagnosis
liaise with the probation officer of clients on a DTTO
involve the key worker and at least one other colleague in making any decision to discharge a client early
allow clients the opportunity to present their case against early discharge
provide clients with information on the service's complaints procedure
provide clients with onward referral to advice, support and harm reduction services and advise clients about when and how they might seek readmission
tell all clients what the discharge protocol is when they are admitted and remind them of it, when and if necessary
carry out an audit of clients who are discharged early.

Agency/ Service Provider

Streamline re-assessments
Providers should ensure that when a client is re-referred or returns to a service with a view to re-admission, the re-assessment process builds on existing knowledge about the client and does not duplicate information which is already available

Keep case review focused
Providers should:

routinely incorporate case reviews into care planning and care management
meet requests for case reviews as quickly as possible - particularly from GPs involved in shared care
focus case reviews on the issue in hand and not involve unnecessary further detailed re-assessment

Conduct an appointments audit
Service providers should:

conduct an appointments audit to identify patterns in unattended appointments and to gather client's suggestions on how systems might be improved. The audit should identify how often and why clinical sessions or booked appointments are cancelled by services
review and redesign the appointment system, if required
operate a range of appointment options, if possible. This could include partial and double booking to minimise time loss; drop-in and 'turn-up by' dates for stable clients; evening and weekend sessions for people in work; and appointments at peripatetic sites for clients who have to travel long distances, or who find travel difficult
develop guidelines on what to do when a client fails to attend. Where possible, this should proactively seek to determine why the client did not attend. This, and the client's level of risk, should determine the course of action to be taken

Manage workforce constraints
Service providers, in consultation with joint commissioners, should:

assess the administrative workload of practitioners and clinical staff and, where necessary, appoint additional administrative cover. Practitioners and clinicians should not spend time on administrative tasks
ensure that service managers do not carry a clinical caseload. Clinical time lost as a result is likely to be offset by a more efficiently managed service
consider the benefits of new initiatives such as the role of nurse consultants and patient groups directives

Develop evidence-based practice
Providers should:

develop mechanisms for remaining up-to-date with new and emerging evidence and approved standards of practice - clinical and managerial
provide staff with access to relevant professional journals. Services could consider developing a local 'journal club', possibly in partnership with a relevant research organisation
develop internal systems for monitoring practice against approved standards
implement strategies to raise practice standards to approved levels where indicated

Establish and maintain clinical governance systems
NHS service providers should:

have in place a governance system for ensuring standards are set and met. This should promote accountable and responsible practice and support continuing quality improvement
ensure that their clinical governance systems interface with those of other health and social care organisations, including Community Mental Health and Primary Care Trusts

Integrated Services

Map local services
Whilst DATs, in accordance with existing guidance, should already be aware of the range of local services, this might be complemented by comprehensively mapping the full range, scope, role and client groups served by all local providers

Provide information on available services to reduce inappropriate Referrals
In accordance with existing guidance, providers should ensure that clear,
up-to-date information about services:

is widely available
is produced in the first languages of key local communities
is delivered through a range of techniques, including help lines (with 24 hour recordings), the internet and printed materials
is designed and adapted for professional and service user audiences. Service users should be consulted on design and content
provides advice on estimated waiting times but encourages clients to attend so that they start to link into the drug treatment system

Develop local common assessment criteria
Assessment should serve a clear and common purpose. Providers should:

develop common screening and assessment criteria and aim to harmonise their assessment protocols
reach common agreement on the key elements of screening and assessment
implement triage assessment. By receiving referrals from generic providers, standardised triage assessment should ensure only appropriate onward referral to specialist services

Work with general hospitals to develop local protocol
[Action on Waiting Groups¹] and local general hospitals should work together to develop a localprotocol for managing drug users admitted to general medical and surgical wards which:

reduces the risk of avoidable self-discharge due to ineffective drug treatment prescribing

ensures planned discharge so that specialist drug treatment is maintained

Develop shared care arrangements with GPs
DATs should:

work in partnership with LHCCs, and lead the development of shared care arrangements within their localities. This should include responsibility for funding the provision of shared care and ensuring its underpinning in accordance with approved standards

Develop integrated care for through and aftercare

DATs should reflect the importance of through and aftercare services in commissioning plans
Drug treatment specialists should regard generic providers as members of the extended treatment and care team

Source: adapted from the National Treatment Agency (NTA) paper "Making the System Work" (NTA 2002)
¹ There is no equivalent in Scotland at present

2. Managing Waiting Lists

Once a client is placed on a waiting list the service provider has a duty of care to ensure that they will receive treatment (Council of Europe 1999).

Allocating priority

For services where there are waiting lists, there may be a case for allocating priority. The EIU Working Groups and the service users' focus groups highlighted the problems associated with allocating priority to those on waiting lists, in particular users' perceptions of what they need to do, or be assessed as doing, to be prioritised for treatment and care. There is a general consensus among service users that you need to be referred through the criminal justice system, or be injecting to stand any chance of prioritisation.

A tool for prioritising waiting lists

If it proves necessary or desirable to allocate priority, agencies should develop clear criteria for allocating such priority and make those criteria known to other partner agencies. Partner agencies should also agree a local protocol for assessing risk where priority is being allocated.

West Sussex Addiction Services have developed a Behavioural Risk Assessment Tool on part of the Enhanced Treatment Outcomes (E.T.O.) Pilots (see Chapter 5). This tool and the guidance notes attached help to ensure that risk is identified in a consistent and measurable way. A copy of this tool is attached at the end of this section.

Client perception

Clients should be actively involved in decisions about their own treatment, care and support. This means that, when they are added to a waiting list, they should be told:

whether any priority ratings have been applied, and the implications that these have for waiting times guarantees
how long the waiting list is and what the expected waiting time is likely to be
what happens if they cannot attend for an offered appointment and they let the service provider know in advance
what happens if they do not attend an appointment without letting the service provider know in advance
what happens if they attend for an appointment but are unable to fully participate due to problems with withdrawal or over-sedation

Individuals, in discussion with their keyworker or care co-ordinator, should be able to make informed choices about where they are referred for treatment. There are a number of factors which should be taken into account, including the preferences of the individual, the size of waiting lists for services and the likely waiting times for treatment (accepting that waiting times will be largely determined by priority cases).

The development of such policies may be helped by national standards of what is an acceptable length of wait for each service. Although these policies would then need to be locally determined, depending on the service and the circumstances, as a minimum they should:

provide for effective risk management by reviewing clinical priorities for clients on the list
include ways of keeping patients and referrers informed of the current waiting times for specific agencies and services
if possible, identify alternative treatment options, including the use of different locations and service providers

Maintaining contact

Agencies and service providers will need to ensure that they have strategies in place that will monitor the situation of each person waiting for treatment. The key objectives of this function are:

monitor the risk of harm from self or other person
prevent loss of motivation and where possible enhance motivation as a precursor to entering treatment
ensure the retention of the individual on the waiting list
provide alternatives as needs change

Key features of a well managed list:

clear managerial ownership and control
senior practitioner and managerial leadership
clear lines of accountability for the management of the list, and clarity in the roles and responsibilities of everyone involved
integrated IT systems so all waiting lists within a DAT area can be accessed, interpreted and audited consistently
consistent application of definitions for national reporting and comparisons to ensure equity for all clients
early warning system in place to identify unacceptably long waiting lists or times
data protection of clients' information guaranteed
information provided to clients on position on list and expected waiting time
information for the public on waiting lists and waiting times

Key Action Points for Managing Waiting Lists - at Client, Agency/service provider and Integrated services level

Level	Action Point
Client	Enhance motivation of clients on waiting lists Providers should work with clients who are waiting for treatment in order to enhance motivation, prevent loss of motivation due to waiting, and improve retention and the effectiveness of treatment
Agency/ Service Provider	Maintain contact with clients on waiting lists Service providers should maintain contact with clients on waiting lists in order to: identify changing need continue to assess and provide interim support and advice to enable clients to reduce drug related risks whilst waiting for treatment actively follow-up clients on long waiting lists who have not been in contact for up to two months Providers should not use waiting times to test a client's motivation. It is the responsibility of service providers to help clients remain motivated whilst waiting for treatment
Integrated Services	Establish clear criteria for prioritising clients DATs should: establish clear local criteria for prioritising clients who need treatment. Criteria should be based on a locally agreed protocol for assessing risk to reduce harm, both to self and others. Protocols should state: the possible outcomes of risk which the protocol aims to reduce or avoid (e.g. overdose, acquisition or transmission of blood borne infections) who is a priority (e.g. pregnant women and their using partners, prisoners due for release) which behaviours are priorities (e.g. chaotic drug use, criminal activity) circumstances that are priorities (e.g. soon to be discharged from hospital) advise generic services who refer to drug services of the criteria for prioritising clients for assessment

Source: adapted from the National Treatment Agency (NTA) paper "Making the System Work" (NTA 2002)

3. Developing Contingency Plans

The report on waiting times in Scotland by the Auditor General (Audit Scotland 2002) states that it is not acceptable to simply leave a list to grow ever larger; management action is required to ensure that clients do not suffer as a result. Problems such as this need to be actively monitored, and all service providers need to ensure that they have early warning systems and contingency plans in place to identify and manage potential waiting list problems.

Anticipating new demands

Increasing the resource capacity of service providers as a means of reducing waiting times may not necessarily provide the 'breathing space' that workers and service planners may be seeking.

For example, expansion of methadone maintenance treatment (MMT) at Ontario's Centre for Addiction and Mental Health did not result in a drop in demand for the clinic-based MMT treatment programme. In fact the patient population was able to continue to grow. There was a broadening of the patient profile in the programme including patients who were better educated, more likely to be employed and less likely to be currently injecting (although with a significant history of past injection drug use). The expansion in treatment availability did not impact negatively on the existing programme, but rather enabled access for a group of higher functioning opioid dependent patients who were previously being deterred from treatment entry by the large waiting lists and the need for priority access for pregnant and HIV positive heroin users (Brands 2000, Type 3).

Examples of where such new demands and expectations may come from include:

new developments in criminal justice services, such as DTTOs and arrest referral schemes
an increase in the prevalence of drug misuse locally
changes in patterns of drug using behaviour, for example greater use of stimulants such as cocaine
difficulties in recruiting and retaining suitably qualified staff
changes within other service providers

Monitoring demand activity

Potential sources of information for monitoring demand activity include: service provider's own process information; the views of service users; data from partner agencies; statistics from the Scottish Drug Misuse Database on numbers of new individuals in contact with services; and national prevalence information.

The monitoring of waiting times is discussed in more detail below.

Key Action Points for Developing Contingency Plans - at Agency/service provider and Integrated services level

Level	Action Point
Agency/ Service Provider	Consider subcontracting elements of service Service providers, in consultation with joint commissioners, should: consider subcontracting elements of their service, if they are experiencing staff shortages or space constraints. For example, a community service with a prescribing function could sub-contract a partner service to run its waiting times support group. By working with its partners and using funds creatively, services should consider extending outwards rather than expanding inwards consider joint appointments or inter-service arrangements for seconding staff when shortfalls arise due to staff sickness or annual leave. By reimbursing locum costs, GP specialists could be recruited to provide temporary clinical cover review the caseload and casemix of their staff. Regular team meetings should ensure that a service's total workload is evenly distributed, care plans regularly reviewed, and plans in place to enable appropriate and timely discharge
Integrated Services	Develop a local contingency plan [Action on Waiting Groups²] should: develop a local contingency plan to manage sudden change in the nature and size of demand for specialist drug treatment services consider scope, and develop protocols for interim services, including prescribing services provided by GPs or local independent contractors involve primary care and Accident and Emergency services in developing contingency plans DATs should: monitor local trends aim to gain prior knowledge of plans to disrupt local drug markets
Integrated Services	Forecast demand and supply In accordance with existing guidance, DATs should develop their abilities to forecast new demand as part of the needs assessment process. This information should be considered against current waiting times and existing capacity, in order to identify the possible impact of new demand on the drug treatment system and inform investment decisions

Source: adapted from the National Treatment Agency (NTA) paper "Making the System Work" (NTA 2002)
²There is no equivalent in Scotland at present

4. Monitoring Waiting Times

Consistency in data recording

Consistency in the recording of waiting times information at a local level is required if waiting lists are to be successfully managed. Data received from Drug Action Team Corporate Action Plans suggest that a number of different recording procedures are in place across service providers, statutory and voluntary, both within local areas and across Scotland. Audit Scotland's review of drug services also found different practices operating in the recording of waiting lists.

Monitoring systems

It has been suggested that waiting times for first treatment episodes should only be measured once comprehensive assessment has been completed and a referral for treatment made. While that information may be helpful to the planning and delivery of services, it is a reality that a person's perceived need for treatment prompts referral and that, for this reason, waiting times should be measured from the date of first referral (or self referral) to the date an individual begins a programme of treatment and care.

Whilst information systems need not necessarily be the same across agencies and service providers, the data collected, the way it is validated and the way it is interpreted needs to be consistent. A core data set should include at least the following items:

client details (age, gender etc)
priority of client
date of referral
date of first contact
date of assessment (if different to first contact)
date the programme of treatment commenced. In a sophisticated system it may be possible to include the dates that subsequent programmes commenced (e.g. aftercare, rehabilitation)
date of discharge/referral to other service
information on 'did not attend' rates

To ensure consistent returns agreed definitions of "waiting time" should be used e.g. maximum length of wait, average length of wait or number of people waiting. A standardised approach to prioritisation and an understanding of the impact of this approach should also be agreed.

Information sharing

Waiting lists contain confidential client-based information and so should be subject to high levels of security access. Only those with a demonstrable need to access the waiting list should be able to do so. Audit Scotland found that not all computerised systems had password protection or an audit reporting facility.

Case study: Good practice in developing waiting list procedures and monitoring waiting lists and times in primary care trusts

Renfrewshire & Inverclyde Primary Care Trust uses a procedure manual, which is given to all those involved in waiting list management. This is also available electronically.

Lanarkshire Primary Care Trust has implemented a comprehensive and effective monitoring system across all its services to manage the time that patients wait according to clinical need. A template has been developed to help clinical teams structure clinical information, helping it ensure consistency in data collection and simplifying reporting mechanisms.

Greater Glasgow Primary Care Trust has developed a comprehensive waiting times reporting mechanism with a standardised approach to all the services it provides.

National Waiting Times Initiative

National work to tackle waiting times in the NHS is currently underway through the National Waiting Times Unit. There are targets in place for inpatient/day case treatment and for the clinical priorities of cancer and heart disease. These national initiatives are being supplemented with local waiting times targets, set by NHS Boards, which reflect local priorities, and which should be identified in Local Health Plans.

A national Waiting Times Database is due to come on-line at the end of 2002. This will contain useful approaches to the management of waiting times in all sectors. It will showcase examples of good practice, some of which may be applicable in a drugs services setting.

There is no waiting time initiative currently operating for drug misuse treatment services. However, ISD Scotland, on behalf of the Executive, has recently gathered detailed information across Scotland on waiting times for drug services to see how this might be improved and monitored in the future. Following analysis of this information it is intended that work be taken forward with the Waiting Times Unit to look at options for the routine monitoring of waiting times, including what national standards might sensibly be set. The options will include the following:

continue to collect waiting times information through the annual DAT planning arrangements
monitor waiting times directly from treatment services on a more frequent basis, possibly through surveys on a quarterly basis
introduce a patient based monitoring system, possibly expanding the existing Scottish Drug Misuse Database dataset

Decisions on how the work will be taken forward will be made later in the year, in consultation with DATs and local agencies.

5. Current Research on Waiting Times - Drug Misuse Research Initiative

The Drug Misuse Research Initiative (DMRI) is a �2.4 million programme of research over the years 2000-2003. It is located within the Department of Health Policy Research Programme and currently comprises 13 studies in the areas of drug treatment and prevention. This includes two studies focusing on waiting times.

Waiting for Drug Treatment - Effects on Up-take and Immediate Outcome (OWL)

This project is headed by Dr Michael Donmall, Director of the Drug Misuse Research Unit, University of Manchester. The project aims to describe the current status of waiting lists and times for drug treatment across England, to study the effects of waiting on treatment uptake and retention, and to investigate the effects of waiting on those seeking treatment. The investigation will have relevance for all those engaged in drug misuse and waiting for care.

The study has three components:

a national survey of the dynamics and management of waiting lists
a prospective study of the effects of waiting time on treatment uptake and retention
an investigation of user perspectives

By identifying critical factors influencing waiting times and their effect, this study will inform policy makers and practitioners, and provide evidence for improved management of problem drug takers at the critical stage of engagement with services.

The project commenced in September 2000 and initial findings from the study will be published around November 2002.

Randomised Clinical Trial of the Effects of Time on a Waiting List on Clinical Outcomes in Opiate Addicts awaiting Out-Patient Treatment

This project is headed by Professor John Strang of the National Addiction Centre.

The project aims to assess:

if time spent in waiting for treatment initiation is associated with an increased risk of treatment drop-out
if time spent on the waiting list is associated with changes in substance use and other key treatment variables (such as frequency of injecting, physical health, psychological health and social functioning)
the economic factors associated with time on a waiting list; and enquire whether it is of policy relevance to know what drug users actually do while they are waiting to begin treatment.

The project commenced in September 2000 and is due to complete in February 2003. Further information on the Drug Misuse Research Initiative is available at: http://www.mdx.ac.uk/www/drugsmisuse/

6. Further resources

National Waiting List Toolkit Project: www.demandmanagement.nhs.uk/toolkit/
Capacity and Demand Management: www.npdt.org/cdm/intro.htm
National Treatment Agency: www.nta.nhs.uk
Audit Scotland: www.audit-scotland.gov.uk
NHS Beacons Learning Handbook: www.nhs.uk/beacons

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