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					Central North West London Mental Health NHS Trust
                          Substance Misuse Service




                Performance Management
                 Substance Misuse Service
                      Annual Report
                  April 2005 – March 2006
Section Contents                                              Page

          Service Director’s Forward Statement                 3
     1 Performance Summary                                     4

      2   SMS Performance on KPI’s                              8
    2.1   Admissions                                            8
    2.2   Care Plans/Treatments                                 9
    2.3   Waiting Times                                        10
    2.4   Planned/Unplanned Discharges                         12
    2.5   12 Week Retention Rates                              13
    2.6   Blood Borne Virus                                    14

      3   Contracts and Finance                                16
    3.1   Sector Contracted Activity Summary                   16
    3.2   Max Glatt Contracted Unit Activity Summary           18
    3.3   Directorate Financial Position                       19

      4 Clinical Governance                                    20
    4.1 Clinical Governance Statement                          20

      5 QuADS Annual Audit                                     23
    5.1 SMS Wide General Findings                              23

      6 Serious Untoward Incidents and Complaints              25
    6.1 Serious Untoward Incidents                             25
    6.2 Complaints                                             30

      7   4 Priority Improvement Area’s                        33
    7.1   Westminster                                          33
    7.2   Kensington & Chelsea                                 35
    7.3   Hammersmith & Fulham                                 37
    7.4   Ealing                                               39
    7.5   Brent                                                41
    7.6   Hounslow                                             43
    7.7   Harrow                                               44
     8 Needs Analysis                                          47
      9   Prisons                                              58
    9.1   Service Descriptives                                 58
    9.2   Holloway                                             63
    9.3   Pentonville                                          65
    9.4   Wormwood Scrubs                                      66
    9.5   Wormwood Scrubs – Mental Health In-Reach             68
     10   Primary Care                                         69
   10.1   Substance Misuse Management In General Practice      69
   10.2   Substance Misuse Management In Community Pharmacy    73
   10.3   Pharmacy Needle Exchange Schemes                     75



                                    2
Service Director’s Forward Statement

This is the third year the Directorate has worked on an evolving performance
management framework. Each year we have tried to take on board the feedback
from key stakeholders on the shape of the report. It is worth noting that, this
years report, despite the expansion of the Directorate, is now more concise and
focused than in previous years.

Contextually this report is written at a time when the environment we operate
within, the NHS as well as more specifically Substance Misuse and Prison
Services, is in a state of constant change, where goalposts and targets are
inconsistent. This must be kept in mind when the reader is trying to understand
the comparison of targets over the past three years. It is also worth noting that
services, such as our Hounslow services, are being tendered out next year
despite the fact that they have exceed most of their local and national key
performance indicators. This poses the question, why invest in performance
management systems in the NHS when the findings are not being recognised,
as in the case of Hounslow PCT, which has decided to tender out all CNWL
Hounslow Substance Misuse Services for 2006/07.

This is the first year we have been able to include any meaningful data from our
prison services and, as you will see from the report; this is an area of significant
growth for the Directorate. In recognition of the growth in prison services, the
Directorate name has now been changed to „Substance Misuse and Prison
Services‟.

I would like to express my sincere thanks and appreciation to all staff for their
contributions in assisting the organisation in meeting its national and local
objectives and performance targets.




Robyn Doran
Service Director




                                         3
Section 1 - Performance Summary
1.1   National KPI’s
Significant changes have been achieved during 2005/06 in relation to quality of
data collection, management and analysis. A key tool implemented more
extensively in 2005/06 with the goal of improving recording compliance and data
quality is the services „Data Quality League Tables‟; this is published monthly to
feedback quality percentage scores of important data variables. However, much
work is still needed in relation to data quality in many other variables and in
terms of achieving 100% compliance with the full recommended local and
national datasets for substance misuse treatment.

The data presented in this report also include the extra activity achieved by the
addition of Brent Sector and the Harrow Sector DAISY connection in terms of
Tier 3 Treatment Admissions (Care Plan Indicator). All other performance results
must be seen in the context of increased activity and increased data quality.

  1st Assessment Admissions

  All clients         : up by 17.4% since 2004/05 / 26.9% since 2003/04
  Drug clients        : up by 25.5% since 2004/05 / 51.6% since 2003/04
  Alcohol clients     : up by 9.9% since 2004/05 / 2.5% since 2003/04
  Inpatient clients   : up by 2.2% since 2004/05 / 26.7% since 2003/04

  Treatment Start Admissions

  All clients         : 70.8% increase in recorded treatment admissions
  Drug clients        : 76.1% of admissions resulted in treatment uptake
  Alcohol clients     : 70.8% of admissions resulted in treatment uptake

  National Waiting Time Target [85%]

  Drug Treatment            : 14% increase to 88% [Achieved]
  Alcohol Treatment         : 21% increase to 80%

  National Planned Discharges Target [70%]

  Drug Treatment            : 6% decrease to 53%
  Alcohol Treatment         : 3% increase to 72% [Achieved]
  In-patient Treatment      : 6% increase to 80% [Achieved]

  All treatment types maintained improvements over 2003/04 performances.

  National 12-week Retention Target [70%]

  Drug Treatment            : 4% increase to 53%
  Alcohol Treatment         : 4% decrease to 37%




                                        4
1.1       Contract and Finance
The Directorate reported an over spend of £10,000 at year-end in balancing
their finances. The directorate also provided good returns against the majority of
its contracts with a few areas to focus on in 2006/07.

1.2       Clinical Governance
Clinical Governance was further consolidated within the Substance Misuse
Service throughout 2005/06. Following last year‟s recommendations, local
committees proceeded to elect chairs longer to serve for twelve months and to
provide representation to the Central Committee.

Clinical Governance is now embedded and integrated to a high level within the
directorate. All sectors now produce annual action plans, which are performance
monitored.

The National Treatment Agency published its Effectiveness Review in 2005. The
emphasis of this report was to focus on the client‟s journey through evidence-
based treatment, which was presented to the Service. SMS Action Plans were
adjusted accordingly.

In the light of this Review, the Central Governance Committee focused on:

         Waiting times for clients,
         Care planning,
         Serious untoward incidents
         User involvement and carer advocacy.

1.3       Clinical Audit (QuADS)
QuADS are a set of Organisational standards for Alcohol and Drug Treatment
Services and represent Quality in Alcohol and Drug Services. The QuAD‟s Audit
seeks to determine whether a range of required clinical standards are upheld
within the organisation, and includes:

         Staff Interviews,
         Client Survey,
         Management Interviews,
         Clinical Notes Audit and
         Site Survey.

Data collection was carried out across 21 sites within the directorate by a team
of staff volunteers.

1.4       SUI’s and Complaints
Overall, SUI‟s for drug clients increased by approx. 3 incidents above the
average of 26 incidents per year (2003/06 average).

SUI‟s for Alcohol clients reduced by 5 incidents below the average of 21
incidents per year (2003/06 average).




                                        5
We are now also working closely with the prison services to ensure that SUI
data capture follows a common pathway which informs both the Prison and
CNWL SUI reporting systems without compromising each other‟s risk
management policies.

The majority of complaints received in 2005 (13 recorded) were informally
resolved with satisfaction from both the clients and service side. Complaints
procedures were complied with. All complaints were thoroughly investigated and
where possible the clients who lodged the complaints were interviewed. Staff
and witnesses involved were also interviewed as relevant and appropriate.
Clinical documentation was also reviewed through the investigation process.

One or two of the complaints related to the joint care and service provisions with
our partner agencies and subcontractors. These have highlighted gaps in the
management and resolve of such complaints. Clear joint protocol and
memorandum of understanding with these partner agencies and subcontractors
will now need to be put into place, notably around the cleaning contract and
catering services with West London MHT for the Max Glatt Unit, which originally
identified these issues.

1.5   Action Plans
This is the first year that the service has developed a service wide performance
management system to monitor 4 Priority Improvement Area Plans. Each sector
has provided the 4 sector priority areas and described why it is a problem, what
actions are planned, how it will be monitored and what the expected outcome is.
These plans will form the basis of more in-depth monitoring and reporting at the
end of 2006/07.

1.6   Needs Analysis
The CNWL E&D Strategy (2005) feeds the Corporate E&D Action Plan (2006-8)
that addresses both Corporate Trust as well as Directorate Based Actions.

Please note that the data shown in this section is from records on our database
system, DAISY. There are currently issues surrounding data quality on a number
of variables that are actively being improved. Over the course of 2005/2006 data
quality and reliability has generally improved and is expected to continue to do so
over the course of 2006/2007 through the use of data quality reporting.

1.7   Prisons
The numbers of prisoners presenting with a clinical need for a specialist
Substance Misuse intervention resulted in CNWL being asked to provide expand
its tier 3 services. Currently, CNWL SMS provide drug services to Wormwood
Scrubs HMP, Holloway HMP and Pentonville HMP and are also contracted to
provide Mental Health and In-Reach at Wormwood Scrubs HMP.

CNWL working in partnership with HMP Wormwood Scrubs has been recognised
nationally as a model of best practice and won the prestigious Butler Trust Award
for Healthcare improvement.

Partnership Working is well in progress with other key agencies, including: RAPT,
CARATs, Short Duration programmes, and all aspects of the Drug Strategy
Group, however the pace is different at each location. Examples of this success

                                        6
include, a dedicated full time CARAT worker on the Treatment Unit (Conibeere
Unit) at Wormwood Scrubs, who are responsible for assessing and planning
aspects of the through care process.

1.8   Primary Care
Substance Misuse Management In General Practice (SMGP)

GP registration on SMGP Schemes continues to grow in K&C, H&F and
Hounslow whilst Westminster maintains its registration levels. Ealing borough
has pulled out of the CNWL SMS managed schemes and opts for a direct PCT
managed scheme.

Client treatment capacity on all schemes improves again during 2005/06 with
Westminster now managing over 600 clients within primary care systems.

Substance Misuse Management In Community Pharmacy (SMMCP)

Pharmacy registrations on schemes improve in H&F with Westminster, K&C and
Hounslow maintaining current levels.

Clients receiving „instalment dispensing‟ through the schemes reduce in
Westminster and K&C whilst are increased in H&F.

Clients receiving „supervised consumption‟ through the schemes increase in
Westminster, H&F and Hounslow whilst are decreased in K&C.

Pharmacy Needle Exchange Schemes (PNX)

Pharmacy registration on schemes are maintained or increased in all boroughs.

Injecting equipment distribution increases in Westminster, H&F and Hounslow.

Used equipment returns:

Harrow             : 8.8%
Westminster        : 46.0%
K&C                : 70.4%
H&F                : 25.4%
Hounslow           : 35.7%




                                      7
Section 2 – Key Performance Indicators

2.1       Admissions

In accordance with the national drug strategy, treatment services aim to
increase both the number of service users in treatment, and access to treatment
services. The admissions graph below shows the number of admissions to Tier
2 and 3 services over 3 years, totalling 3822 in 2003-2003, 4134 in 2004-2005
and 4852 during the 2005-2006 financial year.

  6000                              Admissions
                                                                  4852
  5000                                       4134
                    3822                                          332
  4000                                       325
                    262                                           1829
  3000                                       1664
                    1785
  2000
                                                                  2691
  1000              1775                     2145

      0
                  2003-2004              2004-2005              2005-2006

           Drug               Alcohol               Inpatient        Totals


The overall trend shows an increase in total admission for all three admission
types:

All admissions                : Up 17.4% since 2004/05 and 26.9% since 2003/04
Drug admission                : Up 25.5% since 2004/05 and 51.6% since 2003/04
Alcohol admission             : Up 9.9% since 2004/05 and 2.5% since 2003/04
Inpatient admission           : Up 2.2% since 2004/05 and 26.7% since 2003/04

The larger increases in ‘drug client’ admissions compared to 2004/05 were
experienced in Brent (169 new service records in 2005/06), Hounslow (70.1%
increase), Kensington & Chelsea (25.5% increase) and Westminster (20.6%
increase).

The largest increase in recorded alcohol admissions compared to 2004/05 was
experienced in Ealing (63.8%)




                                         8
2.2       Care Plans/Treatments

The Care Plan graph below shows the number of admissions where a Tier 3 or 4
treatment pathway has been allocated on DAISY. This shows the number of
clients entering Tier 3 or 4 treatments as 2199 in 2003-2004, 2150 in 2004-2005
and 3673 in 2005-2006 financial years.

  4000                                  Care Plans                  3673
  3500                                                              332
  3000
                    2199                       2150                 1294
  2500
  2000              262                        325
  1500              793
                                               840
  1000                                                              2047
   500              1144                       985
      0
                  2003-2004               2004-2005               2005-2006

           Drug               Alcohol                 Inpatient        Totals

The data generally shows an increase in the uptake of treatment by clients during
2005/06, after completing a first assessment admission. Increases in all sectors
contributed to this result. The data also reflects an improvement in quality of
recording client process information on DAISY.


Drug clients          : 76.1% of admissions resulted in treatment uptake
Alcohol clients       : 70.8% of admissions resulted in treatment uptake
All clients           : 75.7% of admissions resulted in treatment uptake



            70.8% increase in all recorded treatment admission
     Drug Treatment Admissions            Alcohol Treatment Admission
          107.8% increase                         54% increase
Brent              : 147 new records No primary alcohol service
Harrow             : 182 new records Harrow              : 62 new records
Ealing             : 186.6% increase Ealing              : 106.6% increase
Hounslow           : 112.7% increase Hounslow            : 51.3% increase
Hamm.& Fulham      : 74.6% increase Hamm. & Fulham : 19.5% increase
Westminster        : 49.6% increase Westminster          : 31.0% increase
Kens. & Chelsea    : 38.4% increase Kens. & Chelsea      : 3.3% increase




                                           9
2.3   Waiting Times

In accordance with the National Treatment Agency objective to increase access
to treatment, waiting times are presented in the following graph. During the
2005-2006 financial year, the target definition changed from ’average wait of
3 weeks’ to ’percentage of clients being admitted within 3 weeks’. Varying
local borough targets have been set as stepping-stones to the target of 85% by
2008. The following figure is an ex-post projection: applying the new 2008 target
to historical data to enable prediction of future performance in relation to the
new target.

  100%                            Wait Times
   90%                                                                85%
               85%
   80%
   70%
   60%
   50%
                                                              88%
   40%                                74%                           80%
   30%       59%                            59%
                   50%                            46%                     46%
   20%
   10%
    0%
                2003-2004              2004-2005               2005-2006

           Drug             Alcohol               Inpatient               Totals


The graph shows good performance improvements over the 3 years with access
times for „drug clients‟ now comfortably exceeding target and access times for
„alcohol clients‟ improving greatly, although just short of target.

In terms of drug client waiting times, an overall 14% improvement has been
achieved including Hounslow (63% improvement to 81%), Brent (98% and
achieving target), Ealing (18% improvement to 62%), Kensington & Chelsea
(14% improvement to 91% and achieving target), Harrow (14% improvement to
95% and achieving target), Hammersmith & Fulham (6% improvement to 94%
and achieving target) and Westminster (2% reduction to 92% and achieving
target).

In terms of alcohol client waiting times, an overall 21% improvement has been
achieved including Hounslow (39% improvement to 88% and achieving target),
Ealing (37% improvement to 58%), Kensington & Chelsea (16% improvement to
90% and achieving target), Harrow (1% improvement to 92% and achieving
target), Hammersmith & Fulham (24% improvement to 82%) and Westminster
(14% improvement to 87% and achieving target).

Access times to inpatient services have remained below target over the past 2
years. The nature of the Max Glatt Inpatient Service, providing service contracts
over 8 boroughs, brings an extra complexity to the efficient management of beds.
The demands from 8 separate boroughs to provide different management

                                       10
strategies, coupled with the problem of managing bed vacancies when clients do
not turn up for admission at short notice contributes to the current performance
rates. It is planned during 2006/07 to pilot more efficient methods of bed
allocation and waiting list management. This would require co-operation from all
contracted boroughs in its successful implementation.

During the 2005-2006 financial year, waiting time targets were set at 3 weeks for
the provision of out-patient drug treatment services, and 2 weeks for inpatient
drug services. The average waiting times for clients starting treatment each
month are presented in the graphs below.


Out-patient Drug/Alcohol Average Waiting Times (monthly performance)

  3.50                                  Wait Time s 2005-2006
  3.00
  2.50
  2.00
  1.50
  1.00
  0.50
  0.00
                     May-05
         Apr-05




                                                Aug-05




                                                                  Oct-05

                                                                           Nov-05




                                                                                                               Mar-06
                                       Jul-05
                              Jun-05




                                                         Sep-05




                                                                                             Jan-06
                                                                                    Dec-05




                                                                                                      Feb-06
             Outpatient Alch                                  Outpatient Drug                          Target



In-patient Drug/Alcohol Average Waiting Times (monthly performance)

  7.00                                 Wait Time s 2005-2006
  6.00
  5.00
  4.00
  3.00
  2.00
  1.00
  0.00
                     May-05
         Apr-05




                                                Aug-05




                                                                  Oct-05

                                                                           Nov-05




                                                                                                               Mar-06
                              Jun-05

                                       Jul-05




                                                         Sep-05




                                                                                             Jan-06
                                                                                    Dec-05




                                                                                                      Feb-06




                  Inpatient Alch                              Inpatient Drug                          Target




                                                         11
2.4    Planned/Unplanned Discharges

The following graph relates to the National Treatment Agency Effectiveness
agenda, aiming to increase the proportion of successful discharges to 70%.
Again this is an ex-post projection as the targets were not set until 2005-2006.

 90%                          Planned Discharges
 80%
 70%          70%
 60%
 50%
 40%                   82%                                                  80%
                                              69% 74%                72%
 30%                                   59%
            52% 55%                                            53%
 20%
 10%
  0%
              2003-2004                  2004-2005               2005-2006

          Drug               Alcohol              Inpatient                Totals


 Planned Discharges               Drug               Alcohol         Inpatient
 Westminster                      55%                 79%               N/A
 Kensington & Chelsea             64%                 70%               N/A
 Brent                            47%                 88%              88%
 Hammersmith & Fulham             53%                 71%              72%
 Ealing                           58%                 66%              79%
 Hounslow                         30%                 87%              83%
 Harrow                           48%                 56%              93%


Current problems associated with recording „discharge types‟ are contributing to
potentially unreliable results. The NTA have not as yet set out discharge codes
to help national consistency except the „Planned‟ and „Unplanned‟ categories.
There is a current lack of consistency across sectors and teams on the correct
definition and usage of some of the DAISY discharge codes and requires work
within 2006/07 to enable more reliable results. It is also worth noting that this
indicator can be misleading in that it is not an indicator of successful treatment
or an indicator of treatment supporting changes to lifestyle and/or health gains. It
is possible that clients could have been retained in treatment for appropriate
periods of time and experienced positive outcomes to treatment but who then
„dropped out‟ of treatment by not discussing the discharge with the service and
who would then be recorded as having an „Unplanned Discharge‟.




                                         12
2.5     12 Week Retention

The following graph also relates to the National Treatment Agency Effectives
Agenda and again this is an ex-post projection of results. Nationally, service
providers within a borough aim to retain clients in consecutive episodes of
treatment for a total of 12 weeks or longer with a range of treatment providers.
Results shown should not be directly compared to this target, as we are
currently only able to measure the length of time each client was retained in
treatment within an individual discreet service within CNWL SMS and not the full
treatment episode within a borough treatment framework. Results are presented
in an effort to monitor and increase our contribution to a borough meeting its
target.

  80%                          12 Week Retention
  70%         70%                                                        70%
  60%
  50%
  40%
  30%
               50%                      49%                      53%
  20%                 44%                      41%                       37%
  10%
   0%
               2003-2004                 2004-2005                2005-2006

               Drug                      Alcohol                       Totals

It is important to note here that the indicator is measuring retention of all clients
discharged within the study periods and so does not include clients who have
been retained longer that 12 weeks who were also active, live clients at the end
of the study periods. It is also important to understand that all sector service
clients are included in this data which means that any clinic/service with a less
than 12 week treatment pathway, contribute high numbers of clients to the data
set an would skew performance results negatively against this indicator.

It is planned in 2006/07 to resolve the monitoring problems related to this
indicator and either measure successive/consecutive treatments or not include
data from services with planned treatment pathway periods of less than 12
weeks.




                                         13
  2.6        Blood Borne Virus

  Nationally it is an objective of Substance Misuse Services to increase the level
  of Hepatitis B & C tests and also the number of Hepatitis B vaccinations. The
  following figure shows performance over the past 2 years. Figures for 2003-
  2004 are not available, though work was completed at this time within CNWL
  Substance Misuse Services.

    1200                            Blood Borne Virus
                                                                      975
    1000                     848
                                                                      257
     800
                             192
     600
                             374                                      506
     400

     200
                             282                                      212
         0
                         2004-2005                                2005-2006

               Hep B Tests                  Hep B Vacc                Hep C Tests



Hepatitis            Hepatitis B Tests              Hepatitis B             Hepatitis C Tests
Activity                                           Vaccinations
Westminster         6 (86% decrease)          7 (92% decrease)         10(58.3%decrease)

Kensington &        57 (36.7% decrease)       153(173.2% increase)     77 (126.5% increase)
Chelsea
Brent

Hammersmith &       1 (no 04/05 service)      20 (no 04/05 service)    39 (no 04/05 service)
Fulham
Ealing              76 (49% increase)         169 (15.8% increase)     104 (112.2% increase)

Hounslow            26 (73.5% decrease)       109 (29.8% increase)     27 (68.2% decrease)

Harrow              46 (no 04/05 service)     48 (no 04/05 service)    (no service)

SMS Totals          212 (24.8% decrease)      506 (35.3% increase)     257 (33.9% increase)


  Westminster and Harrow both suffered in terms of 2005/06 blood borne virus
  activity due recruitment difficulties to the Viral Specialist posts and then being
  vacant for most of the year. Both sectors project better performance during
  2006/07.

  Hammersmith & Fulham did receive some investment in 2005/06 for the cost of
  vaccines but not manpower. The sector provided its recorded activity through

                                              14
existing services at Crowther Market, but could not address the larger need at
multi-agency sites around the borough. This has been corrected for 2006/07 with
the borough commissioning a half specialist post to develop services borough
wide.

Hounslow achieved 51 initiated 1st vaccines (schedule of 3 vaccines per course)
against a contract of 50 and completed 27 schedules (all 3 vaccines) against a
target of 20.

It is planned during 2006/07 that a more consistent performance framework be
implemented across all sectors in relation to Hepatitis tests and immunity status,
schedules (1st vaccinations) initiated and schedules (3rd vaccinations) completed,
re-testing and immunity status as well service penetration in to wider borough
treatment frameworks.




                                       15
Section 3 - Contracts & Finance
3.1      Sector Contracted Activity Summary

Table 1 Outlines the Contracted Activity for Drug and Alcohol Services across
the directorate and the percentage achieved.
Keynote: CSA = Comprehensive Substance Misuse Assessment

Sector                Unit                     Activity               % Achieved
                                               Admissions                 92%
                      CAPS                     CSA                        72%
                                               Caseload                   72%
H&F                                            Transfer In                35%
                      DTC
                                               Caseload                   82%
                                               Admissions                111%
                      Alcohol Team
                                               Caseload                   88%
                                               Admissions                 78%
                      WTC                      CSA                        94%
                                               Caseload                  107%
Westminster
                                               Admissions                 85%
                      Soho Alcohol Team
                                               Caseload                   98%
                      Soho Rapid Access        Admissions                128%
                                               Admissions                 68%
                      CAPS                     CSA                        53%
                                               Caseload                   94%
K&C                                            Transfer In                48%
                      DTC
                                               Caseload                   72%
                                               Admissions                 42%
                      Soho Alcohol Team
                                               Caseload                   41%
                                               Admissions               No Target
Brent                 Junction
                                               Caseload                 No Target
                                               Admissions                133%
                      Gatehouse Drugs
                                               Caseload                  127%
Ealing
                                               Admissions                218%
                      Gatehouse Alcohol
                                               Caseload                  133%
                      Drug and Alcohol         Admissions               No Target
Harrow
                      Team                     Caseload                 No Target
                                               Contacts                  157%
                      Drug Team
                                               Caseload                  138%
                                               Admissions                 82%
Hounslow              Out-Patient
                                               Contacts                  298%
                                               Admissions                134%
                      Alcohol Team
                                               Contacts                  258%


Primary Alcohol Services
Admissions to the primary alcohol services across the Directorate were high with
136.7% of contracted activity being met (excludes Harrow and Brent due to no alcohol
service commissioned or no contracted „admission‟ targets set). This is also true of the
caseload held across the alcohol teams; with 101.4% of contracted activity being
achieved (excludes Harrow, Brent and Hounslow due to no alcohol service
commissioned or no contracted „caseload‟ targets set).

                                          16
The only significantly under-performance on alcohol admissions was
Kensington & Chelsea, which met 42% of contracted target. The service is
shared between Kensington & Chelsea and Westminster; however, the
performance for Westminster (85% of contracted admissions) varies
significantly to that of Kensington and Chelsea. The target set for caseload
capacity was also unmet in Kensington and Chelsea (41% achieved) compared
to 98% achievement for Westminster. These anomalies need exploration during
2006/07. Indeed a review of the K & C Alcohol Service located at Soho Alcohol
Treatment Centre will be undertaken over the next few months.

Drug & Alcohol Services
It is important to note that drug & alcohol services are delivered from a range of
clinics across 8 boroughs. In Kensington & Chelsea and Hammersmith &
Fulham this includes CAPS assessment services where treatment is initiated
and then who transfer a proportion of clients to DTC‟s for longer-term treatment.
Contracted targets for many of the treatment access points in a sector are an
amalgamation of drug and alcohol clients. DTC‟s in these sectors only provide
treatment for primary drug clients and not primary alcohol.

This varying structure and varying commissioning contract requirements across
boroughs; such as Hounslow who use „contacts‟ as a currency while others use
„episodes of care‟ or „admissions‟; makes it difficult to directly group data across
the Directorate to compare to previous years. This problem would need to be
addressed. The new SMS Cluster Management Arrangement in their review of
services with Commissioners would be looking at this problem.

The Directorate achieved 84.3% performance on „admissions‟ contracts. This
performance result reflects admissions to all initial treatment access clinics and
therefore includes primary alcohol clients in some sectors. It does not include
admissions to the DTC‟s in H&F and K&C due to the fact that they admit/transfer
clients that have already commenced treatment at other sector services
(ie.CAPS) and have therefore already contributed to the borough‟s performance
target. Hounslow, Brent and Harrow sectors are also not included because
these services do not currently have contracted targets for admissions to drug
services.

Sectors who operate a CAPS and DTC model (H&F and K&C), are experiencing
blockages within the DTC‟s due to a number of factors including average
retention rates increasing annually. The model does allow CAPS to remain fully
operational for the majority of clients who are primary drug users and do not
want or require long-term treatment or are primary alcohol clients.

The NTA and local commissioners in H&F and K&C have agreed that
admissions and waiting times etc. for the DTC‟s should not impact on borough
or organisation KPI‟s as these clients are already in formal treatment at the time
of transfer admission to their DTC. Performance monitoring should still continue
at a local level for contracting and development purposes.

In Hammersmith & Fulham, it is likely that the contract target for the Drug
Treatment Centre will be renegotiated and subsequently lowered during
2006/07, due to an acknowledgement by commissioners that the length of stay

                                         17
continues to increase. (Contract targets are based on a 24-month length of
treatment. Based on current caseload figures, the average length of treatment of
clients at the Drug Treatment Centre is 42 months).

In Kensington & Chelsea, another contributing factor to reduced admissions to
the Drug Treatment Centre over the last year is that greater use is being made
of other routes of discharge – notably to GP surgeries.

3.2      Max Glatt Unit Contract Activity Summary

Table 2 Outlines contracted activity (Occupied Bed Nights – OBN) and
percentage of contract achieved (Bed Occupancy) across the 8 commissioning
boroughs. The contracted activity for Ealing, Hounslow and Hammersmith &
Fulham represents the 2002 EHH Health Authority re-mapping of finance, based
on activity.

                        Contracted          Achieved
 Borough                                                       % Achieved
                          OBN’s              OBN’s
 Ealing                    2154                1689               78.4%

 H&F                       1900                1277               67.2%
 Hounslow                   86                 1036              1204.7%
 Brent                      453                445                 98.2
 Hertfordshire              439                447                101.8%
 Harrow                     207                205                99.0%
 Hillingdon                 354                328                92.7%
 Barnet                     690                652                94.5%

 Totals                    6283                6079               96.8%

Table 3 The outcome of this activity/financial split remains contentious and
Ealing DAAT, within their Service Level Agreement, continue to set activity at
pre-mapping levels (2002) as shown below. It is important that during 2006/07,
this issue is resolved between the 3 boroughs of the previous EHH Health
Authority.

                        Contracted          Achieved
 Borough                                                       % Achieved
                          OBN’s              OBN’s
 Ealing                    1429                1689               118.2%

 H&F                       1488                1277               85.8%
 Hounslow                  1223                1036               84.7%

 Sub-Total                 4140                4002               96.7%

 Other                     2143                2077               96.9%
 Totals                    6283                6079               96.8%



                                       18
The Max Glatt unit has a maximum capacity of 6935 OBN‟s from 19 beds. The
unit secured contracts for 90.6% of the available capacity. The unit actually
provided 96.8% of contracted activity and 87.6% of the full available capacity.

The OBN loss in 2005/06 totalled 856 (652 not contracted, 204 other reasons),
which represents 2.3 beds vacant throughout the year.

Other reasons for OBN loss include clients who do not attend for admission, an
inability to secure admission of clients at short notice or clients who self-
discharge against medical advice.

The Service Director and Sector Manager are working with the NTA and the
local host PCT for the unit to look at specialist commissioning to enable the
most efficient use of this expensive resource. It is essential that clients waiting
for admission from all boroughs and who are able to attend at short notice are
not held back due to single boroughs, commissioning their own proportion of
beds.

3.3    Directorate Financial Position

The Directorate reported an end of year overspend of £10,000.




                                        19
Section 4 - Clinical Governance

Clinical Governance was further consolidated within the Substance Misuse
Service throughout 2005 and 2006. Following last year‟s recommendations,
local committees proceeded to elect chairs to serve for twelve months and to
provide representation to the Central Committee. This included representatives
from Kensington & Chelsea, Westminster, Ealing, Hounslow and Hammersmith
& Fulham, Harrow, Brent and, from April 2006, Hillingdon.

As SMS continues to enhance good services within prisons, it was decided to
establish a Prison Sector that also sent a representative to the Central
Committee. This ensured the provision of a quality service and best practice
within the prison system.

Each Clinical Governance Committee is producing an Action Plan for 2006.

2005 saw the production of the NTA‟s Effectiveness Review. This focused on
the client‟s journey through treatment and was presented to the Service. SMS
Action Plans were adjusted accordingly.

In the light of the Effectiveness Review, the Central Committee focused on
waiting times for clients, care planning, serious untoward incidents, user
involvement and carer advocacy.

The SUI database, as mentioned last year, is now established and SUI‟s are
discussed at each Local and Central Committee Meeting.

The Central Committee sought to extrapolate recommendations from Root
Cause Analysis that were applicable to SMS as a whole. These fed into action
points for the forthcoming year and those that have been established include:

   1.   A review of Risk Assessments.
   2.   A request to improve interdisciplinary communication.
   3.   The importance of following up referral letters.
   4.   The establishment of a handover policy between clinicians.
   5.   A need to refocus on re-toleration and the prescription of methadone.

Janet Brotchie, the lead for psychology services is currently working on
reviewing and refining tools relevant for SMS outcome monitoring.

The Performance Monitoring Group continues to focus on this area and has
written both brief and extended reports for presentation to the Trust Board. This
committee also looked at ways of more accurately reflecting outcomes in the
key performance areas.

The Substance Misuse Service continues to be well represented at Trust level
including the Trust Clinical Governance Committee, the Trust SUI Committee,
Trust Infection Control (Blood Borne Viruses), the Lead Clinicians‟ Group and
the Appraisers‟ Committee. SMS has also chaired the opening meeting of the
Trust SUI Sub-committee established to look at lessons that might be learnt
from SUI‟s to the benefit of the Trust in general.

                                        20
The SMS and Prison Directorate sends representatives to the Medicines
Management Committee, the Clinical Risk Group, the Equalities and Diversity
Committee, the Hidden Harm Groups, CAMH Services and the Dual Diagnosis
Committee.

The SMS and Prison Directorate representatives are members of the Trust‟s
Medicines Management Committee, Clinical Risk Group, Equalities and
Diversity Committee, Hidden Harm Groups, CAMH Services and the Dual
Diagnosis Committee.

Integrated care pathways for Hidden Harm were developed for all sectors and
have been incorporated into the Action Plans.

The Medicines Management was strengthened. An Action Plan from the local
pharmacists will be included in the Sector Plans for 2006/07.

The Directorate continues to work on its relations with local DAAT‟s (where they
exist). In line with NTA thinking, we have sought to prevent disinvestments and
the loss of services. To ensure best practice, we have sought commissioner‟s
support for growth in the areas of provision of care to stimulant users, to
children and adolescence and those with blood borne viruses. It is recognised
that our own performance stands to be heavily influenced by the performance of
individual DAAT‟s.

As outlined last year, several attempts were made to improve on shared
governance in 2005. This did not go as successfully as was hoped, but
negotiations are continuing in several sectors throughout 2006.

Some sectors are already working closely with Social Services and non-
statutory agency workers.

There are plans in Hammersmith & Fulham and in Hounslow to restructure
service delivery. The intentions of the local commissioners as well as the
viability and advisability of various suggested projects are being addressed.
These will have significant implications for staffing, management, client access
and client convenience.

The Directorate continue to address Research Governance. In keeping with
last year‟s action points, a Corporate Lead for Research and Audit has been
nominated.

The Service has been invited to look once again at the Nationwide Injectable
Project and this is being carefully considered.

The Information and Audit Team was strengthened this year with the result that
the Health Commission review was completed on time.

The QuADS Audit was also completed in 2005 and the results were published
in 2006. Three or Four Action Points for each sector were extracted from the
audit and will be addressed in the forthcoming action plans for next year.



                                       21
The service implemented the NHS Booking system and ICD10 coding was
stepped up. The Information and Audit Team is also addressing the application
of a care planning approach across SMS and the recording of data on the
intranet.

The Service has continued to consult users and to apply recommendations from
User Forums.

The Prison Sector has now been established. A dedicated team is working on
improving services in the prisons for which we have responsibility and this has
generated a lot of interest across UK and abroad. The expertise of the staff is
highly valued and we expect this work to develop in 2006/07.

The Central Clinical Governance Committee continued to provide guidance to
the local groups. The incorporation of the Hillingdon Sector from April 2006 has
led to the decision to review the management system. The proposal to divide
the Service into “Central” and “North Western” sectors will necessitate a
reorganisation of local clinical governance committees in line with the new
managerial structure and action points have been set out for 2006/07.

SMS continues to support DIP and the Criminal Justice Services. Our work with
Accident and Emergency Departments in St Mary‟s Hospital has seen the
publication of the Paddington Alcohol Test.

The Directorate has continued its high level of teaching and training.
Employees of the Directorate were also in demand to give lectures and
seminars countrywide and internationally.

2005 saw the appointment of the tenth Consultant Psychiatrist within the
Substance Misuse Service and Job Plans have been submitted for the Brent
and Hillingdon consultant posts to the Regional Advisor and we are awaiting
approval to set up the Appointments Committees.




                                       22
Section 5 – Clinical Audit (QuADS)
QuADS are a set of Organisational standards for Alcohol and Drug Treatment
Services and represent Quality in Alcohol and Drug Services. The QuADS Audit
seeks to determine whether a range of required clinical standards are upheld
within the organisation, and includes Staff Interviews, Client Survey,
Management Interviews, Clinical Notes Audit and Site Survey. Data collection
was carried out across 21 sites within the directorate by a team of volunteers.

5.1    SMS Wide General Findings
Overall clinical notes were strong in the categories relating to Referrals,
Assessment and Discharge. In particular, the Risk Assessment was completed
in almost all audited notes.

In 95% of cases the referring agency could be identified in the client‟s notes and
in 88% of notes audited information on the reason for discharge/transfer.

97% of clients questioned across the service felt that staff addressed them by
the name they wanted

92% of clients felt that the opening times of the units were convenient for them
and 91% of clients knew their key workers name.

42% for sites had access to The Charter of Service Users Rights and
Responsibilities. Making the Charter of Service User rights more readily
available has begun through the Central Clinical Governance Group and the
Management Team and is to be cascaded to all local groups to action.

85% of clients were told about confidentiality and sharing of information. Clients
signed 85% of consent forms examined, but only 36% had dated this.

80% of units had a poster about the complaints procedure and 61.4% of clients
reported that they knew that they had the right to access their records.

35% of clients reported that they had received a script in a public place. Of
these only 36% had stated that this was in an envelope. Service User‟s privacy,
which is high on SMS management agenda, is being addressed with relevant
instructions to staff via the Central Clinical Governance group. For example, Key
workers are being reminded that prescription should be given to clients following
their one to one session and if this is not possible prescription should be given in
an envelope.

100% of staff interviewed were aware of how to contact social services but only
50% of teams could provide a policy. Making the policies regarding contacting
other agencies more readily available has begun through the Central Clinical
Governance Group and the Management Team and is to be cascaded to all
local groups to action.

Five teams across the directorate had not responded to all referrals in writing
where this had been requested from the referrer. Properly responding to referral


                                         23
letters will be addressed via discussion and training at the Site Administrators
meeting.

5.7% of clients had it documented in their notes that they had received a copy of
their care plan. However 87% of clients had reported that they had talked to
their key worker about what they wanted in the care plan. Only 63% of clients
interviewed reported that they had seen their care plan. However, the clients
signed 75% of the case notes audited.

66% Care Plan Review Dates were missing from audited notes. Only 20% had
commented, in the notes, on "the effectiveness of the care plan".

There is a pan service need to sign, date, and name key workers in all entries
and care plans in the clients' files.

Compliance with regards to Care Plans and Care Reviews is being addressed
immediately at clinic level while being guided through management and clinical
governance channels.

70% of clients reported that they had spoken to their keyworker with regards to
Blood Borne Virus. 87% of staff stated that they had provided clients with
information on safer injecting techniques. Key workers may not be defining their
sessions on Blood Borne Virus to their clients and this information is getting lost.
Again, this is being addressed immediately at clinic level while being guided
through management and clinical governance channels.

50% of staff interviewees responded that they had received some training in
caring for parents who were drug/alcohol users, or in caring for pregnant users,
54% felt that they would like further training. The management team will task
local boroughs with working with their designated nurses to devise and facilitate
additional training.

The vast majority of staff were able to provide leaflets and information relevant
to clients needs (e.g. Harm Minimisation) and rights (e.g. Complaints Procedure)
upon request, suggesting that clients needs are being met in this arena on a
regular basis.

Most staff were also able to access drugs policies and procedures, again
suggesting that these are being used regularly.

Management were able to locate the majority of required Policies and
Procedures upon request suggesting that these are being referred to regularly.

Access to almost all teams is being publicised in the form of opening hours and
referral procedure on all sites.

In addition to the above, each team has been given between 4-5 specific
recommendations to address prior to the next QuADS audit. Progress with
regards to the results will be monitored throughout the year via management
structures and these will provide a focus for the audit next year.



                                         24
Section 6 - Serious Untoward Incidents and Complaints_____
In 2005/06, the service introduced a new database to record, track and report
SUIs and complaints processes. Data collected for 2005/06 are now compliant
with Trust SUI policy and reporting system. New SMS SUI Type Groupings are
used and so only total SUI‟s can be compared with previous years while SUI
categorisation and type groupings represent 2005/06 only.

6.1    Serious Untoward Incidents
There are still some gaps in our local reporting to of SUI‟s to SMS HQ, which
needs to be corrected, notably around abiding by the time limit to initial
reporting of incidents. This is being addressed and reinforced and will be closely
monitored by the SMS Performance Management Group.

For 2005, Harrow has shown a higher reporting of incidents in general. These
are attributed to the positioning of their services and its closer working link with
the Mentally Disordered Offenders Team, which is part of the Multi-Agency
Public Protection Panel (MAPPP). They were until recently also the main
provider for the Arrest Referral Scheme. Similar patterns are likely to emerge in
future as our services across other boroughs are realigned to work more closely
with the Criminal Justice System where an increased number of persistent drug
offenders with volatile and violent behaviour will be seen.

SMS is ensuring that its staff are trained in the care and management of difficult
and potentially violent patients both on the wards and in the community. Equally,
it is ensuring staff complete the basic principle of Root Cause Analysis training
which will add to their competence understanding and reporting on serious
incidents as well as being able to undertake SUI investigation and reporting
where relevant and appropriate.

CNWL SMS has a culturally diverse population. We are conscious of the
religious and belief system of our client group. We have embarked on a cultural
competence-training programme for all our staff with a 100% target achievement
to the end of the year. We are committed to ensure that all our staff do have at
least basic foundation knowledge in understanding the diversity needs of our
client group and reduce the potential for misunderstanding and conflict which
may lead to an avoidable incident, however tedious the latter may be.

We are now also working closely with the prison services to ensure that SUI
data capture follows a common pathway which informs both the Prison and
CNWL SUI reporting systems without compromising each other‟s risk
management policies.

Overall, SUI‟s for drug events would appear to be higher than those with alcohol
problems. We recommend that these two sets of data reporting be closely
scrutinised to ensure that these differences are not just superfluous and under
reporting.




                                        25
Total SUI’s by Drug/Alcohol


                      Total SUIs, All Categories by Substance - SMS 2003/06


           60

           50

           40
                           27                         23
           30                                                                 29

           20

           10              23                         23
                                                                              16
              0
                         03/04                       04/05                   05/06

  Drug SUIs                27                         23                      29
  Alcohol SUIs             23                         23                      16




Annual Variance from the 3 Year Mean


                       Annual Variance from 3 year Average - SMS 2003/06
                     Alcohol Average : 21 per year     Drug Average : 26 per year
              4.0
                             0.7
              2.0
                             2.3                       2.3                    2.7
              0.0
                                                       -3.3
              -2.0                                                            -4.7

              -4.0

              -6.0
                           03/04                     04/05                   05/06
  Drug SUIs                  0.7                       -3.3                   2.7
  Alcohol SUIs               2.3                       2.3                    -4.7




                                               26
In or Out of Treatment at Time of SUI


                          In or Out of treatment at time of SUI - SMS 2005/06
                                       By Substance and Gender


              40

              30
                                       6
                                       3
              20
                                       13                                    3
              10                                                             7
                                       8                                     5
                 0
                                       in                                   out
  Drug/Female                          6                                       3
  Alcohol/Female                       3
  Drug/Male                            13                                      7
  Alcohol/Male                         8                                       5




SUI Categorisations by Drug/Alcohol


                            SUIs by Primary Code and Drug Type
                                        SMS 2005/06
                     35

                     30

                     25

                     20                                                   18

                     15

                     10                     11
                                                                          8
                     5
                                         3
                                         2                                3
                     0
                                      Alcohol                            Drug

  Catastrophic/Death                        11                            18
  Major/Severe                              3                              8
  Moderate/Significant                      2                              3




                                                   27
SUI Category (3:Moderate/Significant) by Type, Substance and Gender


                                  SUI Category 3: Moderate/Significant - SMS 2005/06
                                          SUI Type by Substance and Gender
                        5 SUI's
                        0 Female
                 3      5 Male


                 2
                                  1                               1
                 1

                                  1                               1                      1
                 0
                       Accidental Overdose               Attempted Suicide          Other Reason

  Drug/Female                     0                               0                      0
  Alcohol/Female                  0                               0                      0
  Drug/Male                       1                               1                      1
  Alcohol/Male                    1                               1                      0




SUI Category (4:Major/Severe) by Type, Substance and Gender


                                        SUI Category 4: Major/Severe - SMS 2005/06
                                            SUI Type by Substance and Gender
                       11 SUI's
                 5
                        5 Female
                        6 Male
                 4
                                                          1
                 3
                                                          1
                 2
                                           1              1
                 1       2
                                           1              1             1       1              1
                 0
                     Accidental       Assault w ith   Attempted               Medical
                                                                       Fall               Other Reason
                     Overdose           Weapon         Suicide                Reason

  Drug/Female            0                 1              1             0       1              1
  Alcohol/Female         0                 0              1             0       0              0
  Drug/Male              2                 1              1             0       0              0
  Alcohol/Male           0                 0              1             1       0              0




                                                          28
SUI Category (5:Death/Catastrophic) by Type, Substance and Gender


                                            SUI Category 5: Catastrophic/Death - SMS 2005/06
                                                   SUI Type by Substance and Gender
                                 29 SUI's
                               7 Female
                     8
                              22 Male
                                                               1
                     6
                                                               1                                      1
                                                                                                                1
                     4
                                                                                                      3
                                                      1        5
                     2                                                                                          4
                             3            1           1                    1
                                                                                                      2
                                          1           1                    1             1
                     0
                                                                          No n-
                         A ccidental A ssault with          M edical                 No t Kno wn     Other     Other
                                                     Fall              A ccidental
                         Overdo se     Weapo n              Reaso n                  at this Time   Reaso n   Suicide
                                                                       Overdo se
  Drug/Female                0             0          1        1            1             0            1         1
  A lco ho l/Female          0             0          1        1           0              0            0         0
  Drug/M ale                 3             1          1        0           0              1            3         4
  A lco ho l/M ale           0             1          0        5            1             0            2         0




                                                              29
6.2    Complaints
It would appear that the majority of complaints received in 2005 were informally
resolved with satisfaction from both the clients and service side. Complaints
procedures were complied with. All complaints were thoroughly investigated and
where possible the clients who lodged the complaints were interviewed. Staff
and witnesses involved were also interviewed as relevant and appropriate.
Clinical documentation was also reviewed through the investigation process.

One or two of the complaints related to the joint care and service provisions with
our partner agencies and subcontractors. These have highlighted gaps in the
management and resolve of such complaints. Clear joint protocol and
memorandum of understanding with these partner agencies and subcontractors
will now need to be put into place, notably around the cleaning contract and
catering services with West London MHT for the Max Glatt Unit, which originally
identified these issues.

With the implementation of the Criminal Justice System into the Treatment
Agenda, CNWL Substance Misuse Services now work closely with the Drug
Intervention Programme across a number of boroughs. We also have inpatient
contract provisions with the Prison Services, namely Wormwood Scrubs HMP,
Pentonville HMP and Holloway HMP. The one complaint which was received
from one of the prisons also highlighted the need to develop joint complaint
procedures to deal with future cases of similar sorts, so as to avoid and resolve
any potential conflict around the NHS and Prison custodial care management of
clients in drug treatment.

Overall, the main remark to note is that where possible and acceptable, most
complaints resolve are initially undertaken within an informal setting. This is a
good practice approach and helps maintain the therapeutic relationship between
client and keyworker, which is crucial to the treatment effectiveness of our
clients. Data showed that complaints against keyworker specific have been low
in proportion to the number of clients/staff ratio across the service.

As with the main recommendation for the SUI report, we propose similar action
plan for our staff to improve on their response and management of our clients
complaints. These are:

   Staff needed to embark on Cultural Competency ad customer care training at
    least once a year
   Weekly community group with attendance from domestic services and
    catering
   Sectors to review their client‟s handbook, and be explicit about the
    expectations involved in the treatment process
   Joint protocols to be in place with partner agencies where relevant all
    through the patient agreed care pathway system as defined by the NTA
    Models of Care framework.
   Complaints data are standing agenda items on all Clinical and Performance
    Management meetings.
   Staff training and familiarity with Trust complaint procedure are regularly
    appraised at supervision.


                                        30
All SMS Complaints by Source



                        All SMS Complaints by Source - 2005/06
                                      Staff Complaint
                                           8%[1]
                  Other
               Professional
                Complaint
                  8%[1]



            Other
          Complaint
           15%[2]

                                                                                           Client
                                                                                         Complaint
                                                                                          69%[9]




All SMS Complaints by Source and Type



                                                    Complaint Type - All SMS

                        12



                                      2
                           8
                                      2
                                      1
                                      1
                           4

                                      3
                                                          2
                                      1                                                         1
                           0
                                                                    Other Professional
                               Client Complaint   Other Complaint                         Staff Complaint
                                                                        Complaint
  Staff Attitude                      2
  Staff Competence                                                                              1
  Blank                               2
  Treatment/Care Refusal              1
  Treatment/Care Discharge            1
  Treatment/Care Plan                 3                   2
  Misconduct                          1




                                                     31
All SMS Complaints by Resolution



                                Complaints Resolution - All SMS
                                                        1




                                                        10




                                                        3

                                                      Outcome

  Ongoing                                                1
  Complainant does not w ish to                         10
  pursue
  Complainant satisfied w ith                            3
  actions




                                                 32
Section 7 – 4 Priority Improvement Area’s

The following Priority Action Plans are taken from the Sectors Clinical
Governance Action Plans, the Sectors QuAD‟s Action Plans or other Sector
Action Plans for 2006/07.


7.1   Westminster

1. Issue : Uptake of BBV screening within treatment services

Why is this a   Both DAISY and NDTMS have identified high numbers of
problem         people who have not had tests for hepatitis C and/or who have
                not had a hepatitis B vaccination. For public health reasons
                and because this is now an NTA key performance indicator,
                the sector will ensure that we move to 100% of all clients being
                offered hepatitis screening, and vaccination where needed.

Action Taken    Funding for an additional BBV Clinical Nurse specialist will be
/ to be Taken   sought from the DAAT. This will enable an additional 4 off-site
                clinics to be developed in the voluntary sector and/or hostels,
                so that the hard-to-reach group is targeted.

                In addition, funding for a part-time phlebotomy nurse will be
                requested for 6 months to monitor number of blood tests, track
                results, identify health needs of clients, and link clients in with
                relevant treatment services.

                Sector representative (Kostas Agath) to represent the sector on
                Westminster DAAT‟s strategy on Harm Reduction.

                Discussions on BBV/HIV/STI‟s will be recorded on clients‟
                notes or on care plan, as identified in Quads audit.

Ongoing         Monthly monitoring of DAISY activity in relation to existing BBV
Monitoring      work and action taken as needed to ensure that the sector
                shows a month-by-month improvement in performance.

                Sector case note/care plan audit will monitor discussions re
                BBV

(Planned)       If additional funding available, 4 additional off-site clinics will be
Outcome         developed in year and the number of Hep B vaccinations and
                Hep C tests will increase by 100%
                If no additional funding is forthcoming, screening and
                vaccination will increase by at least 50% on the 2005/6 figure
                Increase in recording of BBV discussions in casenotes/ care
                plans of 10% in SRAC and Westminster Treatment Centre,
                using Quads audit from Nov 2005 as a baseline.


                                        33
2. Issue : Monitoring SUI’s and Incident reports monthly

Why is this a   The sector clinical governance forum needs to improve its use
problem         of SUI‟s and untoward incidents as a learning tool that will lead
                to service improvements and staff development.

Action Taken    Sector has developed a database and all SUI‟s and Incidents
/ to be Taken   will be reported on a monthly basis to the clinical governance
                forum.

                Detailed discussion will occur quarterly and records kept of
                learning outcomes

Ongoing         Clinical governance minutes and sector database
Monitoring

(Planned)       Improved response to SUIs and untoward incidents as
Outcome         evidenced by actions taken in response to them.

                Learning identified and actions taken where needed.

                Discussions shared with individual teams and recorded in
                minutes




3. Issue : Hidden Harm and Child Protection

Why is this a   Quads audit identified that many staff do not feel sufficiently
problem         knowledgeable about working with pregnant drug users and
                parents.
                Data entry on Daisy concerning children/families is incomplete.

Action Taken    Use sector training budget to ensure that at least 50% of
/ to be Taken   practitioner staff attend level 1 Child Protection training in
                2006/7

                Improve data entry on Daisy by 20% in year

Ongoing         Monitor Daisy entry on quarterly basis
Monitoring

(Planned)       25 staff are trained in 2006/7
Outcome         Daisy entry improved by 20%




                                      34
4. Issue : Improve compliance with NDTMS:


Why is this a Completion of NDTMS data in the sector improved significantly
problem       in 2005/6, but it is important to ensure this improvement is
              maintained in 2006/7


Action Taken Pathway completion to reach 90% in all services in 2006/7
/ to be Taken All new practitioner and administrative staff to undertake
              DAISY training within one month of joining the service
              .

Ongoing         Records of new starters attending DAISY training
Monitoring      Monthly NDTMS data


(Planned)       Compliance rates achieve 90% for each tier 3 service by March
Outcome         2006/7




7.2   Kensington & Chelsea

1. Issue : Development of Sector Audit Group

Why is this a   Need to improve consistency and quality of case notes. Yearly
problem         audit to become an integral part of quality control


Action Taken    Establishment of Audit group and to undertake case note audit
/ to be Taken   in each unit covered by K/C


Ongoing         Section Audit Group
Monitoring      Clinical Governance Forum
                Local Business Meetings
                Supervision


(Planned)       Undertake 1 Audit per year as well as QUADS audit
Outcome




                                     35
2. Issue : Access to CAPS K/C
Why is this a   Need to extend the drop-in available in their parts of the
problem         borough (outside of CAPS)

Action Taken    To investigate potential to set-up alternative drop-in at Sexual
/ to be Taken   Health Clinic and the Blenheim Project.

Ongoing         DAISY
Monitoring      Sector Clinical Meeting
                CAPS Clinical Meeting

(Planned)       Yearly Audit to establish effectiveness of Action
Outcome


3. Issue : Operational Policy at CAPS
Why is this a   New operational policy required for CAPS in response to
problem         changes in DTC Operational Policy and service needs change.

Action Taken    Team Co-ordinator, case note and Nurse Consultant to discuss
/ to be Taken   Operational Policy Draft

Ongoing         Sector Clinical Governance Forum.
Monitoring      Local clinical meetings.

(Planned)       Sector clinical governance forum
Outcome



4. Issue : Cultural Competence Training
Why is this a   Trust requirements that all staff have training
problem

Action Taken    To identify training for staff over two years in CAPS, DTC and
/ to be Taken   Family Therapy.
                Equality and Diversity training to be noted in Personal
                Development Plan

Ongoing         Setting up of records if courses achieved
Monitoring      Supervision

(Planned)       Audit achievement at year end.
Outcome




                                       36
7.3   Hammersmith & Fulham

1. Issue : Medicines Management
The sector facilitates medication dispensing to clients from its Dispensing and
Monitoring Unit at Crowther Market. Over the year 2005/06 a number of
medication errors have highlighted some systemic problems between clinical
and pharmacy systems.

Why is this a The problem relates to the safe management of medicines for
problem       clients and stems from practice differences between medical
              and nursing staff and pharmacy staff.

Action Taken A full review of practices and systems is planned for 2006/07.
/ to be Taken
Ongoing       The work is to be carried out via the Dispensing and
Monitoring    Monitoring Steering Group. An internal sector audit will be
              completed at 6 months in relation to medication errors and
              satisfaction of staff in relation to system changes.

(Planned)       A 20% reduction in medication errors and satisfactory
Outcome         feedback from staff and clients.




2. Issue : Risk Management
The sector experienced 6 SUI‟s in 2005/06, which was a reduction of 4 from
2004/05 (n=10). The Sector Clinical Governance Group has achieved important
outcomes in 2005/06 in relation to systems development for monitoring and
reviewing all SUI‟s and general incident reporting.

Why is this a It is imperative that all clients receive ongoing risk assessment
problem       and planning which is audited by the presence of new Risk
              Assessment Forms in case notes every 3 months.

Action Taken A review of practices and systems is planned for 2006/07 to
/ to be Taken identify and confirm any systemic problems of interest.

Ongoing         The work is to be carried out via a Risk Management working
Monitoring      group led by the sector Consultant Psychiatrist. An internal
                sector audit will be completed at 6 months in relation to Risk
                Assessment Forms in case notes.

(Planned)       A 10% increase in Risk Assessment Forms completed at entry
Outcome         into the service is required.




                                      37
3. Issue : Care Planning
The annual QuADS audit for 2005/06 identified a number of area‟s for action in
terms of care planning and recording within the sector.

Why is this a Audit suggests that further work is required in the area of care
problem       planning for all clients of the sector.

Action Taken A full review of practices and systems is planned for 2006/07.
/ to be Taken
Ongoing       The full action plan will be monitored directly through the
Monitoring    Clinical Governance Group with involvement from Senior
              Clinicians and Team Co-ordinators.

(Planned)       Local targets (70%) will be set to ensure sustained
Outcome         improvement in „Clients having and being given Care Plan‟,
                „Care Plans dated and signed by Staff‟‟, „Care Plans seen by
                client and signed‟, „Keyworker named on the Care Plan‟,
                „Responsible person for each goal identified‟, „Review dates
                recorded on Care Plans‟, „Care Plan reviews carried out‟.




4. Issue : Borough Service Re-Modelling
It is the plan within Hammersmith & Fulham that all services participate in a
borough service re-modelling or Drugs and Alcohol provision.

Why is this a The boroughs PCT, DAAT and Commissioning Groups feel
problem       that evidence, along with recommendations from the NTA and
              the results of a recent local consultation process in the borough
              during 2005/06 that co-located services will yield higher
              performance and quality of provision to the residents of
              Hammersmith & Fulham.

Action Taken In October 2006 it is planned to initially move the Social
/ to be Taken Services Drug & Alcohol Team into the Crowther Market
              premises (managed by CNWL).

Ongoing         Monitoring of the process will be managed through the
Monitoring      Strategic Commissioning Group (with CNWL SMS
                membership) and Internally by the Co-location Working Group.

(Planned)       Social Service co-location in Crowther Market
Outcome




                                      38
7.4   Ealing


1. Issue : Client Retention


Why is this a Their has been a reduction in retention rates for the Alcohol
problem       Team


Action Taken      Examine Date
/ to be Taken     Exclude Transfers to MGU
                  Look at aftercare planning


Ongoing           Examine monthly data
Monitoring        Quarterly Review of Retention figures


(Planned)      Increase retention by 16% to hit the national target in 06/07
Outcome




2. Issue : Prescribing Trends


Why is this a There is a growing expenditure within the DTC for
problem       supervised consumption


Action Taken      Review all clients on supervised consumption
/ to be Taken     Ensure that we work within the Guidelines of 3 months and
                   this is not extended without agreement in the MDT meeting


Ongoing           Team Coordinator will have an up to date list of all
Monitoring         clients on supervised consumption and dispensing
                   regimes.


(Planned)         £30,000 reduction in overspend position by year end
Outcome




                                      39
3. Issue : Complaints


Why is this a We received 5 complaints from clients on the Max Glatt Unit.
problem


Action Taken       Improve hotel services to the MGU
/ to be Taken      Improve the clients view of staff attitudes
                   Improve the activities available on the MGU


Ongoing            Weekly Community Meeting
Monitoring         6 weekly Domestic Meeting
                   Monthly monitoring of the education programme
                   Client Satisfaction questionnaire to be completed twice on
                    the unit


(Planned)          Reduction in the complaints received from the MGU clients
Outcome




4. Issue : Women in Treatment


Why is this a The sector ratio of male to female has fallen to 4.:1 in 2005/06
problem


Action Taken       Assist the DAAT in implementing the DAAT Action Plan for
/ to be Taken       Women


Ongoing            Monthly information on ratio of male to female to be viewed
Monitoring          by the Team Co -ordinators


(Planned)          Reduce ratio to the national level of 3:1
Outcome




                                       40
7.5   Brent

1. Issue : Staffing
With the partnership between CNWL and Turning Point formally commencing on
1st April 2006 a team of medical, practice and administrative staff was required
to deliver the service.
Why is this a Prior to April 2006 the Junction Service the Turning Point staff
problem           complement included 2 WTE administrative staff and 1 WTE
                  Team Co-ordinator with a Manager seconded from CNWL. 1
                  WTE Staff Grade Psychiatrist, 6 Substance Misuse
                  Practitioners and 1 Administrative Manager were employed at
                  significant cost through agencies. New posts were required to
                  staff the service including additional administrative staff, a
                  Consultant Psychiatrist and a Clinical Psychologist.
Action Taken The Brent Sector has managed a number of recruitment drives
/ to be Taken and some posts are yet to be filled due to a national shortage
                  of skilled substance misuse professionals and the increasing
                  demands to expand the workforce in this field. The Brent
                  Sector Manager was recruited in April 2005, a Team Co-
                  ordinator confirmed in post soon after. Three Substance
                  Misuse Practitioners have accepted posts to join two staff
                  already in post. Interviews for a Consultant Psychologist take
                  place at the end of May 2006. Adverts for administrative staff to
                  go out by July 2006.
Ongoing           Situation requires ongoing monitoring and aim is to have full
Monitoring        staff complement of medical, clinical and practice on contracts
                  by September 2006.
(Planned)         To have partnership service fully staffed
Outcome

2. Issue : Care Planning
The Substance Misuse Service Annual QuADS Audit found that 70% of audited
clients notes contained a care plan. Service users or their key-worker did not
sign 40% of care plans audited and there was poor evidence that care plans are
systematically reviewed. We aim to improve these areas, ensuring that all
service users are actively involved in developing a clear care plan that both they
and their key-worker sign. Care plans will include review dates and where
progress will be reviewed with the service user and goals adjusted.
Why is this a Ensuring care plans are in place for all services users is a
problem           basic requirement for specialist substance misuse services set
                  out by the National Treatment Agency. Failure to improve this
                  area will reflect poorly on the service and deny service users
                  their right to active involvement in their treatment.
Action Taken Through internal audits conducted by practice staff, staff
/ to be Taken meetings supervision.
Ongoing           Audits will enable improvements to be monitored and help to
Monitoring        improve standards.
(Planned)         The plan is to achieve an improvement demonstrated through
Outcome           95% of audited notes having a written care plan with a clear
                  review date signed by the service user and key-worker by
                  August 2006.

                                        41
3. Issue : Confidentiality and the Right of Access to Information.
40% of clients surveyed in the QuADS Annual Audit indicated that they had
been informed of their right to view their personal information and 80% were
aware of their rights regarding confidentiality and sharing information.

Why is this a These issues can be key factors in determining if service users
problem       access and remain engaged with substance misuse treatment
              services. A failure to improve service user awareness could
              affect our ability to attract and retain service users.


Action Taken To have discussion with team including feedback of Audit
/ to be Taken results and agree actions to be taken by team to improve. To
              raise issue at service user meeting.


Ongoing         Discussions with staff
Monitoring

(Planned)       Aim for 75% of service users to report that they have been
Outcome         informed of their right to view their personal information and
                90% to report awareness of their rights regarding confidentiality
                and sharing information.




4. Issue : Retention In Treatment


Why is this a National Treatment Agency have set targets for Substance
problem       Misuse Services to retain service users in treatment for a
              minimum of 12 weeks in order to enable treatment gains.


Action Taken Sector Manager to meet with Commissioner to agree
/ to be Taken targets for the Junction Service. Team to look at issues
              that may affect retention and consider strategies to
              improve this area.


Ongoing         Retention will be monitored through DAISY
Monitoring

(Planned)       Retention targets to be agreed with Brent Commissioner
Outcome


.



                                         42
7.6   Hounslow

1. Issue : Planned Discharges


Why is this a During the year the planned discharges for the drug services in
problem       the borough dropped by 20% on the previous year, which
              represents a significant underperformance on the National
              Treatment Agencies targets.


Action Taken Review the Minimum Data Set, to ascertain whether this is a
/ to be Taken data entry problem.

                Carry out a review on 25% of clients that leave in an un-
                planned way on a quarterly basis.


Ongoing         Monitoring % of planned discharges each quarter.
Monitoring

(Planned)       Increase the planned discharges by 40% to achieve national
Outcome         target




2. Issue : 12 Week Retention


Why is this a   As part of the NTA „s Effectiveness of Treatment Agenda, drug
problem         services are required to contribute to the borough 12-week
                retention target for all clients. Within the borough the 12-
                retention rate dropped below the NTA 70% target to 61%.


Action Taken    The team to discuss factors which may affect retention and
/ to be Taken   consider strategies to improve this.


Ongoing         Retention will be monitored through DAISY
Monitoring


(Planned)       Increase 12-week retention above the NTA Target
Outcome




                                     43
3. Issue : To develop an exit strategy from the borough.


Why is this a   Commissioning intentions for 2006/07 include the re-tendering
problem         of Tier 3 Specialist Prescribing services.


Action Taken    Develop a     comprehensive     corporate   exit   strategy   and
/ to be Taken   implement.


Ongoing         Led from Directorate Management Group with responsibilities
Monitoring      held by Cluster and Sector management and clinical
                governance groups.


(Planned)       The service should exit from provider status in Hounslow as
Outcome         professionally and safely as possible.



7.7   Harrow

1. Issue : SUI and Complaints
Harrow sector submits significantly more SUI reports than other SMS sectors.
This is due to the historical links that the service has with the local Mentally
Disorders Offenders Team, local MAPPP, and Child Protection Team.

Why is this a The need to develop a more co-ordinated response to risk and
problem       to close the loop on the local suicide and SUI audit, particularly
              around the area of dual diagnosis.


Action Taken A Suicide & SUI Monitoring Group is now in place to implement
/ to be Taken and monitor the recommendations for the annual Suicide Audit
              and joint Mental Health & SMS SUI reports. The local Dual
              Diagnosis Steering Group is to be reconfigured for 2006/7 and
              will feed into the local Mental Health Clinical Governance
              Group, where SMS will now be represented.


Ongoing         Action plan to be developed by the local Dual Diagnosis
Monitoring      Steering Group


(Planned)       To work with the new CNWL Dual Diagnosis Manager to
Outcome         develop and implement the new Dual Diagnosis Strategy




                                       44
2. Issue : Risk
The current SMS premises in Bessborough Road are no longer suitable for the
sector service.

Why is this a Once in the waiting area, clients have access to the whole
problem       building, making it difficult to contain aggressive or disruptive
              client behaviour.


Action Taken Plans for new premises have considered security and the
/ to be Taken movement of clients through the building. A decision on
              planning permission is due in June 2006.


Ongoing         Successful move and appropriate security measures taken in
Monitoring      the new premises.


(Planned)       A successful relocation of the service.
Outcome




3. Issue : Clinical Governance – Information Sharing
Local multi-agency Information Sharing Policy is inadequate.

Why is this a The boundaries of information sharing in relation to DIP,
problem       Harrow PPO scheme, ASBO‟s and Community Safety are
              unclear and in need of review.


Action Taken This issue has been raised at the DIP Steering Group, the PPO
/ to be Taken Steering Group, the DAT Treatment Group and with the lead
              for the CDRP. Advice has been taken form CNWL Risk
              Manager.


Ongoing         Review of all sector Information Sharing protocols to ensure
Monitoring      consistency.


(Planned)       Implementation of an Information Sharing Protocol, which is
Outcome         agreed and owned by the key stakeholders




                                       45
4. Issue : Contracted Target Performance
Problem of identifying Tier 2 and Tier 3 activity separately, for the purposes of
separating the SLA targets and costs.


Why is this a Harrow DAT is reviewing the tender for a tier 2 drug service.
problem       Different data requirements exist for tier 2 and tier 3 services.


Action Taken To review the SLA's for the service and re-profile activity to
/ to be Taken reflect tier 2 and 3 client groups, in preparation for the
              restructure and re-tendering of the tier 2 function.


Ongoing          Via the SLA activity data targets
Monitoring


(Planned)        Separate SLA's for tier 2 and 3 services with true and accurate
Outcome          costing and activity targets




                                        46
Section 8 - Needs Analysis (Equality & Diversity)
Introduction
The E&D Agenda is governed by a series of Acts and Regulations: Race
Relations (Amendment) Act 2000; Disability Discrimination Act 2005; Equality
Act 2006; Employment Equality (Sexual Orientation) Regulations 2003;
Employment Equality (Religion and Belief) Regulations 2003; Employment
Equality (Age) Discrimination Regulations 2006.

In CNWL NHS trust the profile of the E&D has been raised exponentially during
the last year: E&D is currently addressed within a systematic framework
(provided by the CNWL E&D Strategy, 2005) with its implementation overseen
by the CNWL NHS Trust E&D Committee (since 2005) that reports directly to
the CNWL Trust Board.

The CNWL E&D Strategy (2005) feeds the Corporate E&D Action Plan (2006-8)
that addresses both Corporate Trust as well as Directorate Based Actions.

It is the above action plan that shapes the content of the performance
management report this year. It is worth pointing out however that in the
absence of quantitative data, there is descriptive exposition on, rather than
omission of, a particular area of interest from this report. Furthermore in the
various sections there is reference to performance management relating data
on two levels: the first relates to hard data relating to client activity; the second
relates to changes at the service level that future reports are expected to show
client related activity data on.

Please note that the data shown in this section is for data that has been
recorded on our database system, DAISY. There are currently issues
surrounding data quality that are actively being improved. Over the course of
2005/2006 data quality and reliability has generally improved and is expected to
continue to do so over the course of 2006/2007 through the use of data quality
reporting.




                                         47
8.0.1 Client Ethnicity

Figure NA1 shows the level of data quality in regards to recording of client
ethnicities on the Substance Misuse Client Administration System, DAISY. In
2005/2006 the highest level of ethnicity data was recorded (96.71%) and the
lowest was in 2004/2005 (98.16%).


                     NA1 - % Ethnicity Recorded (Target > 95% )

  100.00%
   90.00%
   80.00%
   70.00%
   60.00%                                                                                        2003/2004
   50.00%                                                                                        2004/2005
   40.00%                                                                                        2005/2006
   30.00%
   20.00%
   10.00%
    0.00%
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Figure NA2 shows the total number of alcohol clients by ethnicity. The trend
shows an increase in ethnic minority clients from 36.63% in 2003/2004 to
37.36% in 2005/2006.


                               NA2 - Alcohol Clients Ethnicity

  1400
  1200
  1000
   800
   600
   400
   200
     0
         Ethnic      White      Blank       Ethnic      White      Blank   Ethnic      White       Blank
         Minority    British                Minority    British            Minority    British

                    2003/2004                          2004/2005                      2005/2006




                                                        48
Figure NA3 shows the total number of drug clients by ethnicity. There has been
an increase in ethnic minority clients from 40.90% in 2003/2004 to 42.84% in
2005/2006.


                                NA3 - Drug Clients Ethnicity

  1800
  1600
  1400
  1200
  1000
   800
   600
   400
   200
     0
         Ethnic      White      Blank   Ethnic      White      Blank     Ethnic       White     Blank
         Minority    British            Minority    British              Minority     British

                    2003/2004                      2004/2005                        2005/2006




8.0.2 Workforce

Figure NA4 shows the total number of SMS staff by ethnicity. There has been a
decrease in ethnic minority staff from 57.67% in 2003/2004 to 45.15% in
2005/2006.


                                 NA4 - Workforce Ethnicty

  140
  120
  100
   80
   60
   40
   20
    0
          Ethnic        White British    Ethnic          White British     Ethnic        White British
          Minority                       Minority                          Minority

                2003/2004                      2004/2005                            2005/2006




                                                    49
Figure NA5 shows the % of SMS staff by gender. There has been little variation
over the three-year reporting period.


                              NA5 - Workforce Gender

  70.00%
  60.00%
  50.00%
  40.00%
  30.00%
  20.00%
  10.00%
      0.00%
               Male      Female       Male      Female     Male      Female

                  2003/2004              2004/2005            2005/2006




8.0.3 Service User & Carer Involvement

The Directorate has continued to develop service user involvement initiatives
throughout 2005/06 and includes:

       SMS/Trust wide Steering Committees such as H&F Phase 4 Steering
        Group, SMS Artspace Steering Group, a selection of service gardening
        Steering Groups, the CNWL Vocational Needs Advisory Group and the
        SMS Hidden Harm SC.

       SMS Service User „Forums/Consultations‟

       H&F SMS Vocational Needs (ETE) developments including 2 ex-service
        users employed by CNWL with Honorary contracts, both working on a
        voluntary capacity in SMS at present. 2 ex-service users co-presentation
        at in SMS Conference (Oct 05) and CNWL OT Conference (May 06), SMS
        Vocational Services Action Plan includes increasing client access to
        vocational/work opportunities within CNWL through the CNWL User
        Employment Programme and Service User work placement
        („Development Worker‟) scheduled to commence July 2006 based within
        OT SMS.

       Staff teaching/training, including Thames Valley University teaching
        sessions, ex and current service user participation, 4 per annum and 5 th
        year medical training (4 x year), service user participation.

       SMS staff recruitment includes ongoing service user training,
        representation in recruitment process, eg interview panels, appointment
        etc.



                                         50
       Service User Questionnaires/Evaluations including Service User „Psycho-
        social‟ Questionnaire completed & outcome disseminated Oct 05, OT
        „Physical Activities‟ Questionnaire (Nov 05) and ongoing service user
        satisfaction questionnaires & evaluations (nursing, OT, Psychology etc)

8.0.4 Stimulant Drugs

Figure NA6 shows the number of clients with a stimulant as their primary drug.
For SMS as whole there is very little variation in the figures over the three-year
reporting period.


                   NA6 - % Clients with a Stimulant Primary Drug

  25.00%

  20.00%

  15.00%                                                                2003/2004
                                                                        2004/2005
  10.00%                                                                2005/2006

      5.00%

      0.00%
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Figure NA7 shows the % of clients with a stimulant drug as their secondary
drug. There has been a decrease over the reporting period with 15.97% in
2003/2004, 12.52% in 2004/2005 and 14.23% in 2005/2006.


               NA7 - % Clients with a Stimulant Secondary Drug

  30.00%

  25.00%

  20.00%
                                                                        2003/2004
  15.00%                                                                2004/2005
                                                                        2005/2006
  10.00%

      5.00%

      0.00%
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                                                 51
8.0.5 Dual Diagnosis/Co-Morbidity

Figure NA8 shows the % of clients with a recorded dual diagnosis. There is
only a small variation in figures over the reporting period with a 4.6% increase in
2005/2006 since 2003/2004 and a 13.9% decrease since 2004/2005.


                NA8 - % Clients with Recorded Dual Diagnosis

  4.00%
  3.50%
  3.00%
  2.50%                                                                                  2003/2004
  2.00%                                                                                  2004/2005
  1.50%                                                                                  2005/2006
  1.00%
  0.50%
  0.00%
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8.0.6 Injecting Behaviour

Figure NA9 shows the % of clients injecting by gender. Since 2003/2004 there
has been a decrease in male injectors from 14.22% to 9.08% in 2005/2006 and
a decrease in female injectors from 9.98% to 6.61%.


                         NA9 - % Clients Injecting by Gender

  16.00%
  14.00%
  12.00%
  10.00%
   8.00%
   6.00%
   4.00%
   2.00%
   0.00%
                Male        Female              Male         Female           Male       Female

                   2003/2004                       2004/2005                      2005/2006




                                                   52
Figure NA10 shows the total number of clients injecting by age group. The
largest figure in 2003/2004 was 154 for 31-35 year olds, in 2004/2005 it was 75
for 26-30 year olds and in 2005/2006 it was 93 for 36-40 year olds.


                   NA10 - Clients Injecting by Age Group

  180
  160
  140
  120
  100
   80
   60
   40
   20
    0
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        2003/2004
        2004/2005
        2005/2006
        <16 16-    21-   26-   31-    36-    41-    46-     51-   56-    61-   66- 70+
            20     25    30    35     40     45     50      55    60     65    70




Figure NA11 shows the total number of clients admitted to the Injectables clinic
at Chelsea & Westminster Hospital.


                NA11 - Clients Admitted to Injectable Clinic

  12

  10

   8

   6

   4

   2

   0
         Male       Female           Male          Female         Male         Female

             2003/2004                  2004/2005                       2005/2006




                                            53
8.0.7 Blood Borne Virus

Figure NA12 shows the total number of Blood Bourne Virus tests and
vaccinations given to clients. Since 2003/2004 there has been an increase in
vaccinations by 68.8% and 34.5% since 2004/2005. The total number of tests
carried out has increased by 394.6% since 2003/2004 and decreased by 3%
since 2004/2005.


              NA12 - Blood Bourne Virus Tests and Vaccinations

  600

  500

  400

  300

  200

  100

    0
             Vaccs       Tests     Vaccs          Tests         Vaccs             Tests

                2003/2004               2004/2005                  2005/2006




8.0.8 Hidden Harm

Figure NA13 shows the % of child location of clients with children. The graph
shows that most children live with another parent for all three years.



                 NA13 - Child Location of Clients With Children

    100%
     90%
     80%
     70%
                                                                        Other Parent
     60%
                                                                        Other
     50%
                                                                        In Care
     40%
                                                                        Home With Client
     30%
     20%
     10%
        0%
                 2003/2004       2004/2005          2005/2006




                                             54
Figure NA14 shows the % of child location of family therapy service clients with
children. The graph shows that most children live at home with the client for all
three years.


           NA14 - Child Location of Family Therapy Service Clients
                                With Children

    100%
     90%
     80%
     70%
                                                                          Other Parent
     60%
                                                                          Other
     50%
                                                                          In Care
     40%
                                                                          Home With Client
     30%
     20%
     10%
      0%
               2003/2004            2004/2005          2005/2006




8.0.9 Women

Figure NA15 shows the % of all clients by gender. There has been very little
variation over the reporting period.


                               NA15 - Client Gender

  80.00%
  70.00%
  60.00%
  50.00%
  40.00%
  30.00%
  20.00%
  10.00%
   0.00%
              Male         Female        Male          Female      Male           Female

                 2003/2004                      2004/2005             2005/2006




                                                55
Figure NA16 shows the % of all alcohol clients by gender. There has been a
decrease in male clients from 36.65% in 2003/2004 to 26.33% in 2005/2006.
There is little variation for female clients.


                      NA16 - Alcohol Client Gender

  40.00%
  35.00%
  30.00%
  25.00%
  20.00%
  15.00%
  10.00%
   5.00%
   0.00%
            Male      Female     Male      Female     Male      Female

               2003/2004            2004/2005            2005/2006




Figure NA17 shows the % of all drug clients by gender. There has been an
increase in male clients from 37.33% in 2003/2004 to 45.34% in 2005/2006.
The % of female clients has increased from 12.67% in 2003/2004 to 16.36% in
2005/2006.



                       NA17 - Drug Client Gender

  50.00%
  45.00%
  40.00%
  35.00%
  30.00%
  25.00%
  20.00%
  15.00%
  10.00%
   5.00%
   0.00%
            Male      Female     Male      Female     Male      Female

               2003/2004            2004/2005            2005/2006




                                    56
Figure NA18 shows the total number of women‟s and maternal health
assessment carried out. Since 2003/2004 there has been an increase by
103.5% of women service assessments and a decrease by 40.9% of maternal
health assessments.


          NA18 - No. Womens & Maternal Health Assessments

  350
  300
  250
  200
  150
  100
   50
   0
        Women      Maternal   Women          Maternal   Women      Maternal
        Service     Health    Service         Health    Service     Health

             2003/2004             2004/2005                 2005/2006




                                        57
Section 9 - Prisons
9.1   Services Descriptives
The Substance Misuse Service (SMS) currently manages three teams based at
HMP Holloway / YOI, HMP Pentonville and HMP Wormwood Scrubs. SMS also
manages a Mental Health In-Reach team based at Wormwood Scrubs. HMP
Wormwood Scrubs Substance Misuse Service commenced on 1 September
2003, HMP / YOI Holloway commenced 1 June 2005 and HMP Pentonville
commenced 1 April 2006. Previously it was recognised that a significant
number of prisoners arriving in reception presented with Drug and Alcohol
dependence, and often with Psychiatric Co-Morbidity. The numbers of prisoners
presenting with a clinical need for a specialist Substance Misuse intervention
resulted in CNWL being asked to provide such a service at 3 major London
Prisons. Since entering prisons CNWL have concentrated on the following in
order to address the management of this vulnerable population group.

CNWL working in partnership with HMP Wormwood Scrubs has been
recognised nationally as a model of best practice and won the prestigious Butler
Trust Award for Healthcare improvement.

Systems and Structures
The CNWL clinical leads at each prison are fully integrated within a Clinical
Governance framework to all aspects of prison development work. Including:
Drug Strategy, Safer Custody, Healthcare Management, Clinical Governance,
Medicines Management (drugs and therapeutics), Inter-agency liaison including
referral pathways and Partnership Development. This is operating at a different
pace at each location.

Teaching and training has been introduced for all staff on the Substance Misuse
Service on a weekly basis, and monthly for all prison staff who work on the unit.
This includes links with CNWL MH Trust, who often provides teaching and
training within the prison service. This covers a range of academic, training, and
operational subjects. The major emphasis is placed on ensuring confidence and
competence in the delivery of our clinical care programmes.

Self Harm and Suicide
There is serious concern within the prison estate about the high levels of Self
Harm and suicide amongst the prison population. On Admission to Prison in
England and Wales it has been identified that most suicides occur during
transition periods into the prison service, for example: 11% occur within the first
24 hours of admission to prison, 33% occur within the first week and 47% occur
within the first month. Important to service provision is the fact that 62% of the
above incidents are diagnosed as problematic drug users.

Safer custody groups monitor self-harm figures in each local prison. These
figures have given rise to serious concern indicating the vulnerability of this
population group. CNWL quickly responded to these concerns regarding suicide
and self harm and have implemented a referral procedure based on fast tracking
into treatment client who require a substance misuse intervention directly from
the point of reception into the prison. Clients now commence treatment within
their first 24-hours in prison. Our future plan is to enhance faster access to

                                        58
treatment by commencing opiate substitute prescribing on the first night
prisoners arrive in reception including weekend when previously no staff were
on hand to provide this service other than weekdays.

Similarly, the time of self-harm incidents has and is being monitored at
Wormwood Scrubs. CNWL have found that most episodes of Self-Harm have
occurred in the evening and during the night. Surplus to comprehensive
teaching and training for all substance misuse staff additional operational
guidelines on the management of this vulnerable population group during the
night time period have been provided.

A Comprehensive Weekly Regime has been set up to address psychosocial
needs at all 3 sites. At Holloway access has been created for all women on the
Substance Misuse Service to partake in all prison activities through the
„normalisation‟ process. This enables to women in our care to be treated as
equals within the context of available activities and education programmes.

Treatment Options
CNWL have significantly expanded the range of treatment options, comparable
to treatment availability within the NHS. Previously treatment included Ad Hoc
methadone prescribing along side Dihydrocodeine (DF118). Currently the
treatment protocols; developed in line with the evidence base, include:
Methadone Detoxification and Maintenance, Buprenorphine, Benzodiazepine
Reduction, Zopiclone, Clinical monitoring and management of stimulant users
and comprehensive symptomatic management. In future plans include
enhanced Methadone Maintenance programmes and Lofexidine. Strict
monitoring of opiate-based analgesia post-detoxification has also been ongoing
for a considerable period of time.

Access to Treatment
CNWL have significantly increased the routes of access to its treatment
services. Most significantly, clients can now be referred back to the
detoxification unit from Wing Location this is important improvement in treatment
availability within the current context which accepts that prison supply reduction
measures are not fully affective. Additionally, clients now have access to
treatment via faster and more user-friendly treatment-telephone referrals.
Finally, access to staff has also improved, with clients now being allocated a
named nurse, having daily access to a Substance Misuse Doctor, regular
access to a GP clinic and regular access to a Substance Misuse Consultant.
Application forms are available for all prisoners to access Genito-urinary
Medicine (GUM) clinics, Dental Clinic, Radiology and Wound Care
Management.

Alcohol Treatment
CNWL places much emphasis on the management and treatment of those
prisoners presenting with Alcohol withdrawal features. The objective is to
prioritise treatment interventions in order to reduce the risk of seizure activity.
The management of Alcohol withdrawals is now carried out on the substance
misuse unit and has proven an effective measure in the overall reduction of
seizure activity as compared to this being managed on „wing‟ location. As with
Drug Treatment, all service users / prisoners commence appropriate prescribing
for alcohol withdrawals in the reception area. Appropriate Alcohol protocols have


                                        59
been implemented in addition to a range of adjunct medications in response to
vitamin deficiency, and the potential for seizure activity.

Meaningful Lives
The lack of structured amenities in the past has proven detrimental to
Substance Misuse Clients, and may have impacted on Self Harm and suicide
rates. This programme has been set up jointly by CNWL and Prison Service
staff on all 3 sites and includes the following:

   Group work (including Drug Awareness, Relapse Prevention, Risk
    Reduction, Blood Borne Viruses and Loss of Tolerance)
   General Health care issues and mental Health
   Improved monitoring of Assessment, Care in Custody and Teamwork
    (ACCT, formerly SH52)
   Additional blankets, snacks and access to fluids (to address nutritional
    instability)
   Easy access to Listeners, chaplaincy and religious services
   Association, exercise and regime
   Library
   Interpreters
   CNWL has been most keen to provide a culture of respect and dignity for
    our client group that are often marginalised.

Additionally, at Wormwood Scrubs, clients also have access to Gym and Sauna
facilities.

Partnership Working
Partnership Working is well in progress with other key agencies, including:
RAPT, CARATs, Short Duration programmes, and all aspects of the Drug
Strategy Group, however the pace is different at each location. Examples of this
success include, a dedicated full time CARAT worker on the Treatment Unit
(Conibeere Unit) at Wormwood Scrubs, who are responsible for assessing and
planning aspects of the through care process. A formalised referral pathway
from our service to the Mental Health In-Reach team has been developed at
Wormwood Scrubs and this will be rolled out across all 3 sites.

Through care Input
CNWL recognises the importance of the through care process, and is keen to
ensure that all prisoners who are provided with a Substance Misuse intervention
are adequately prepared to continue the treatment pathway in the community
and seriously address the issues around loss of tolerance. This will be become
the primary focus of an Integrated approach under the IDTS programme.

Other programmes delivered in the through care process include:
    P-ASRO (Prisoners Addressing Substance Related Offending)
    Cognitive behaviour programme (12 weeks) to sentenced prisoners
    Relapse Prevention
    Offending behaviour-enhanced thinking skills
    One to one key-working and aftercare support




                                       60
Integrated Drug Treatment System-pathfinder site (IDTS).
The drug and alcohol treatment services are at HMP Wormwood Scrubs and
managed by CNWL will be part of the implementation of the integrated drug
treatment system-pathfinder site (IDTS). HMP Wormwood Scrubs will receive
funding as part of the National Pilot Sites to deliver on all aspect of IDTS. A
number of sites have been identified nationally to take part in this scheme that
will eventually inform the national roll out of similar service provision to all prison
services. This will include:

       Improving clinical management.
       A more integrated and effective through-care process and discharge
        planning based on collaboration and partnership work.
       A 28 day structured care package of psychosocial support for prisoners
        with problematic drug use
       Clinical monitoring of stimulant users-PSO 3550 -minimum 72 hours
       Maximization of health gains and treatment compliance
       Education for all prisoners in preparation for discharge-managing
        potential risks
       A more effective and integrated approach to the management of this
        vulnerable population group

Key words in this approach include: Equity, Comparability and Evidence Base.

Data Collection and Analysis
Improved data collection and quality checking has been implemented for the
2006-2007 financial year. Limited data is available for the 2005-2006 financial
including this report. Using existing data and the knowledge of what will be
collected in future, we can produce a series of objectives that the teams will aim
to achieve. There are currently no specific targets that we report on and
therefore the objectives will be for internal purposes.

The substance misuse objectives will be based around the following:

   Ethnicity (analyse differences between clients and prison population)
   Types of Detoxification / Maintenance and Alcohol Treatment (the different
    treatment types)
   Discharges/Transfers (measure the success of treatment types etc)
   Referrals/Admissions (analyse differences between clients and prison
    population and where they are referred from e.g. at reception or from wing)
   24hr wait between referral and treatment (Waiting Time Target, for new
    admissions)
   72hr wait between referral and treatment for referrals from „wing‟ location.
   Concealing (analyse the effectiveness of combating concealing)

The In-Reach team objectives will be based around the following:

   Ethnicity (analyse differences between clients and prison population)
   Types of treatment
   Referrals/Admissions (analyse differences between clients and prison
    population and where they are referred from e.g. at reception or from wing)
   24hr Wait between referral and assessment
   Average transfer wait between 218 and 1st medical recommendation
                                          61
   Average transfer wait between 1st and 2nd medical recommendation
   Average transfer wait between 1st medical recommendation and transfer

Over the course of the 2006-2007 financial year, the new dataset (currently
being collected) will be analysed and it is expected that these objectives will be
expanded to reflect a more comprehensive database.

Future Vision

    Hepatitis B Vaccination programmes to become an integral part of service
     delivery at each prison location. Alongside a comprehensive Blood Borne
     Virus management strategy.

    Implementation of the integrated drug treatment system-pathfinder site and
     to inform national roll out of improved clinical management.

    A more integrated and effective through-care process and discharge
     planning working closely with all of our partner agencies.

    Expanding on the current structured care package of psychosocial support
     for prisoners with problematic drug use

    Clinical monitoring of stimulant users-PSO 3550 -minimum 72 hours

    Maximization of health gains with easy access to condoms, needle
     exchange and injecting paraphernalia.

    Maintain the strict monitoring of opiate-based analgesia post-detoxification.

    Provision of education for all prisoners in preparation for discharge-
     managing potential risks such as loss of tolerance.

    A more effective and integrated approach to the management of this
     vulnerable population group




                                        62
9.2        Holloway – Substance Misuse
An in-patient detoxification unit and an outpatient maintenance prescribing
service are available to all prisoners at HMP Holloway who require drug and/or
alcohol detoxification or maintenance treatment. The service is accessible by
open referral within the prison.

Figure PrHO1 shows the total number of clients on the caseload per month.
The average for the financial year was 85.

   160                               PrHO1 - Total Clients
                                                                   140
   140       128
                           123
   120              108                                      105
                                    100               100                                 99
   100                                                                   95


      80

      60

      40
                                            25
      20

       0
            Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06


Figure PrHO3 shows the breakdown of the clients by ethnic group. Out of 1,023
clients, 713 (69.70%) of them were white British. In future reports these figures
will be compared with the total prison population ethnicity breakdown.
                                                                              Blank

                                 PrHO3 - Percentage Ethnicity                 Not Stated

   100%                                                                       Other


      90%                                                                     Chinese

                                                                              Other Black
      80%
                                                                              African

      70%                                                                     Caribbean

      60%                                                                     Other Asian

                                                                              Bangladeshi
      50%
                                                                              Pakistani
      40%                                                                     Indian

      30%                                                                     Other M ixed


      20%                                                                     White and Asian

                                                                              M ix White and Black
      10%                                                                     African
                                                                              M ix White Black Caribbean
       0%                                                                     White Other

              Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-               White Irish

               05 05     05 05    05 05 05 06          06 06                  White British


                                                 63
Figure PrHO4 shows the different reasons for discharging clients. Out of 553
clients, 414 (74.86%) where discharged because they had completed treatment.
For breaching their treatment agreement, 97 (17.54%) clients were discharged.

                           PrHO4 - Percentage Discharge Reason
   100%

                                                                      TRC     BRE
    80%
                                                                      NON     DRO
    60%
                                                                      REF     MOV

    40%
                                                                      DEA     OTH

    20%
                                                                      NKN

      0%
                Jun-   Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
                 05    05    05   05  05    05   05   06   06   06

TRC : Treatment Complete                BRE : Breach of Treatment Agreement
NON : No Code Entered                   DRO : Dropped-Out
REF : Referred On Release               MOV : Moved Prison
DEA : Death                             OTH : Other Reason
NKN : Not Known


Figure PrHO5 shows the number of clients who concealed drugs while on the
unit. A total of 4 clients were discovered to be concealing during the financial
year.


                                 PrHO5 - Total Concealing

  Mar-06

  Feb-06
  Jan-06

  Dec-05
  Nov-05

  Oct-05
  Sep-05
  Aug-05

   Jul-05

  Jun-05

            0                       1                       2                   3




                                            64
9.3       Pentonville – Substance Misuse

An in-patient detoxification unit and an outpatient maintenance prescribing
service are available to all prisoners at HMP Pentonville who require drug and/or
alcohol detoxification or maintenance treatment. The service is accessible by
open referral within the prison.

Figure PrPT1 shows the total number of clients on the caseload per month. The
average for the financial year was 232. This data is based on CNWL working in
a advisory capacity and without the provision of a dedicated unit.
                                PrPT1 - Total Clients


  300

                 236                                              244
  250
                                          217
  200

  150

  100

   50

      0
                Jan-06                   Feb-06                  Mar-06



Figure PrPT3 shows the breakdown of the clients by ethnic group. Out of 697
clients, 323 (46.34%) of them were white British. In future reports these figures
will be compared with the total prison population ethnicity breakdown.
                                                                    Blank
                         PrPT3 - Percentage Ethnicity
                                                                    Not Stated
   100%                                                             Other

      90%                                                           Chinese

                                                                    Other Black
      80%
                                                                    African
      70%
                                                                    Caribbean

      60%                                                           Other Asian


      50%                                                           Bangladeshi

                                                                    Pakistani
      40%
                                                                    Indian

      30%                                                           Other M ixed

      20%                                                           White and Asian

                                                                    M ix White Black Caribbean
      10%
                                                                    White Other
          0%                                                        White Irish

                Jan-06           Feb-06                 Mar-06      White British



Pentonville only recently joined CNWL and therefore there are some data quality
issues that are currently being addressed. We expect to provide more detailed
statistics in future reports.




                                         65
9.4        Wormwood Scrubs – Substance Misuse

An in-patient detoxification unit and an outpatient maintenance prescribing
service are available to all prisoners at HMP Wormwood Scrubs who require
drug and/or alcohol detoxification or maintenance treatment. The service is
accessible by open referral within the prison.

Figure PrWW1 shows the total number of clients on the caseload per month.
The average for the financial year was 114.

  160                                PrWW1 - Total Clients

            134                                                     136               133
  140                                                    128
                                            121
                        116                        115
  120             108
                              95      97
  100                                                          91         89

   80

   60

   40

   20

      0
            Apr- May- Jun-    Jul-    Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
             05   05   05     05       05   05   05   05   05   06   06   06


Figure PrWW3 shows the breakdown of the clients by ethnic group. Out of
1,363 clients, 704 (51.65%) of them were white British. In future reports these
figures will be compared with the total prison population ethnicity breakdown.

                                                                           Not St at ed
                              PrWW3 - Percentage Ethnicity
                                                                           Ot her


                                                                           Chinese
 100%
                                                                           Ot her Black

                                                                           Af rican

  80%                                                                      Caribbean

                                                                           Ot her Asian


  60%                                                                      Bangladeshi


                                                                           Pakist ani

                                                                           Indian
  40%
                                                                           Ot her M ixed

                                                                           Whit e and Asian
  20%
                                                                           M ix Whit e and Black Af rican


                                                                           M ix Whit e Black Caribbean

      0%                                                                   Whit e Ot her
            Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar-
                                                                           Whit e Irish
             05   05   05  05    05   05   05   05   05   06   06   06
                                                                           Whit e Brit ish




                                              66
Figure PrWW4 shows the different reasons for discharging clients. Out of 305
clients, 240 (78.69%) where discharged because they had completed treatment.
For breaching their treatment agreement, 37 (12.13%) clients were discharged.

                          PrWW4 - Percentage Discharge Reason
   100%
    90%
    80%                                                                              TRC   BRE

    70%
                                                                                     NON   DRO
    60%
    50%
                                                                                     REF   MOV
    40%
    30%                                                                              DEA   OTH

    20%
                                                                                     NKN
    10%
     0%
               Apr- May- Jun-   Jul-   Aug- Sep- Oct-   Nov- Dec- Jan-   Feb- Mar-
                05   05   05     05     05   05   05     05   05   06     06   06



TRC : Treatment Complete                     BRE : Breach of Programme
NON : No Code Entered                        DRO : Dropped-Out
REF : Referred On Release                    MOV : Moved Prison
DEA : Death                                  OTH : Other Reason
NKN : Not Known


Figure PrWW5 shows the number of clients who concealed drugs while on the
unit. A total of 4 clients were discovered to be concealing during the financial
year.

                                       PrWW5 - Total Concealing



  Feb-06

  Dec-05

  Oct-05

  Aug-05

  Jun-05

  Apr-05

           0                             1                          2                       3




                                                  67
9.5       Wormwood Scrubs – Mental Health In Reach

The team is a multidisciplinary service dedicated to the assessment of treatment
of prisoners in HMP Wormwood Scrubs who have severe and enduring mental
illness. They also provide support services and professional consultation to
primary care services with HMP Wormwood scrubs prison. In addition the team
provides a liaison and through care service with NHS providers in the
catchments boroughs that link with the prison.

Figure PrIR1 shows the total number of clients referred and assessed by the
team between July 2005 and March 2006. A total of 553 referrals were received
of which a total of 556 clients were assessed in this period.
  100              PrIR1 - Total Clients
                                                  90                      Total Referred
   90
                                                       84                 Total Assessed
                                             77
   80
                    73                  72
                         68   67
   70                                                                          65 62
                                   64                                 59 61             58 62
   60
                                                                 54
                                                            49
   50

   40
   30
          20 18
   20
   10
      0
          Jul-05    Aug-05    Sep-05    Oct-05    Nov-05 Dec-05       Jan-06   Feb-06   Mar-06



Figure PrIR2 shows the average waiting time for the reporting period. The
overall average time from referral to referral received was 2.15 days. The overall
average time from referral received to assessment was 3.67 days.
                   PrIR2 - Average Wait                     Avg. Referal to Received

   7
                                                            Avg. Received to Assess
   6

   5

   4

   3

   2

   1

   0
          Jul-05    Aug-05    Sep-05    Oct-05    Nov-05    Dec-05    Jan-06   Feb-06      Mar-06




                                                  68
Section 10 - Primary Care__________________________
10.1   Substance Misuse Management In General Practice (SMGP)

The Primary Care Service provides a GP shared care initiative in the form of
SMGP Schemes across Hounslow, Hammersmith & Fulham, Kensington &
Chelsea and Westminster. The SMGP Schemes aim to take 'stable' methadone
using clients and place them with a General Practitioner, who not only continues
to prescribe Methadone Mixture for them, but who also takes care of their
primary health care needs. Named GP Liaison Workers, from both statutory and
voluntary sector services are available to provide specialist support to GPs.

The overall objectives of the schemes are:

      To encourage and support GPs who already work with people with
       substance misuse problems to continue to develop expertise in this area.

      To provide an opportunity for less involved GPs to become involved.

      To continue to develop models of co-operation and collaboration
       between GPs, community pharmacists, voluntary sector services, mental
       health teams, social services departments and specialist substance
       misuse services.

      To improve access to treatment/prescribing services.

      To continue to develop models for safer practice

The new GP Contract, commenced 01/04/04, and was expected to encourage
significant further interest from GPs in both substance misuse and/or alcohol
misuse if Primary Care Trusts (PCTs) opted to support Enhanced Services for
these areas as laid out in the new GP Contract. Despite some initial interest,
PCTs have subsequently chosen not to support Enhanced Services for primary
alcohol largely due to financial limitations. However, Enhanced Services for
substance misuse are now in place for all PCTs other than Westminster who
have yet to finalise service criteria.

The Governments NHS Plan target of 30% GPs being involved in substance
misuse treatment through GP shared care schemes has remained for 05/06 and
most PCTs have used this figure with which to base their local targets. From the
data we can see that all boroughs have met this target despite some localities
having a history of difficulty when attempting to engage GPs into treating
substance misusers, the new GP Contract doing little to alleviate this.

From our experience to date it appears that those PCTs that have been active
in supporting their GP shared care scheme, both financially and also by keeping
shared care high on their agenda, benefit most in stimulating interest from GPs
and subsequently recruitment.

It should be noted that any increase in GP recruitment on to SMGP Schemes
results in an increase in availability of client places within primary care. This
allows for drug treatment centres to refer stable methadone users (and in some

                                       69
cases buprenorphine users) out into primary care thus creating vacancies for
substance users not yet in treatment. Hounslow have GP Practices on the
SMGP Scheme who are not currently treating substance users due to the local
drug treatment centre not having clients stable enough for a primary care
setting, although this is now beginning to change.

Kensington & Chelsea SMGP Scheme also has a number of client vacancies in
primary care due to increases in GP membership onto the SMGP Scheme.
Under new GP Contract Enhanced Service conditions, GPs are paid £1066 per
annum for being members of the SMGP Scheme and as such we need to
ensure that GPs are not awaiting clients with which to work with. This will be an
ongoing focus of discussion throughout 06/07.

As well as the Hounslow Enhanced Service SMGP Scheme, for which data is
included in this report, there is also a „Local‟ Enhanced Service for the treatment
of substance users based in a voluntary service setting and is funded to provide
up to 3 clinical sessions. By end 05/06 this service was providing care and
treatment to a further 52 substance users. CNWL SMS is not commissioned to
manage this service.

Westminster PCT has yet to finalise a service specification for GP shared care
based on the new GP Contract. This is cause for concern as it has resulted in
restricted scheme development as well as no formal agreement for which to
recruit new GPs on to the scheme.




                                        70
        (Fig 10.01) SMGP Scheme: GP Registrations by Sector
      The number of GP‟s registered on the scheme against locally set targets.

                         SMGP Scheme : GP Registrations by Sector
 60

 50

 40

 30

 20

 10

  0
           Westminster         K&C                H&F            Ealing          Hounslow

02/03          26               10                16              43                12
03/04          50               19                28              50                21
04/05          51               34                29                                20
05/06          50               41                37                                28




      (Fig 10.02) SMGP Scheme: % Registered of all GP’s
      Percentage of GP‟s registered per PCT against locally set targets.

                          SMGP Scheme : % Registered of all GP's
60%

50%

40%

30%

20%

10%

0%
           Westminster         K&C                H&F            Ealing          Hounslow

02/03         24.8             11.5               16.3           24.6              10.4
03/04         47.6             21.8               28.6           28.6              18.3
04/05         48.6             39.1               29.6                             17.4
05/06         47.6             47.1               37.6                             24.3




                                             71
          (Fig 10.03) SMGP Scheme: Registered GP Practices
          Percentage and number of GP practices registered per PCT.


                             SMGP Scheme : Registered GP Practices

 16


 12


  8


  4


  0
              Westminster        K&C                 H&F         Ealing       Hounslow

02/03
03/04
04/05             15              13                  6                          8
05/06             15              14                  9                          9




          (Fig 10.04) SMGP Scheme: Client Registrations
          The number of clients registered with the scheme.

                                SMGP Scheme : Client Registrations
 700
 600
 500
 400
 300
 200
 100
      0
               Westminster         K&C                H&F            Ealing    Hounslow

 02/03             409             113                    65          61             9
 03/04             507             153                    75          102            20
 04/05             547             114                119                            24
 05/06             610             131                130                            36




                                                72
10.2   Substance Misuse Management In Community Pharmacy (SMMCP)

The Primary Care Service provides SMMCP Schemes across Hounslow,
Hammersmith & Fulham, Kensington & Chelsea and Westminster comprising
supervised consumption and dispensing in instalments.

It is commonly known that pharmacists play an integral part in the delivery of
health promotion and the safe monitoring/dispensing of prescriptions whilst also
building a good rapport with their clients, this scheme recognises the day to day
work of the pharmacist with their substance misusing clients. The SMMCP
Schemes incorporate two levels of involvement:

Core Service
The 'core service' includes an agreement by pharmacist, GP and client to work
together identifying any concerns before they become problems in order that
they may be resolved as quickly and safely as possible i.e. missed doses of
medication, unacceptable behaviour, health concerns, intoxication.

Additional Services
The 'additional services' are available to clients already signed up to core
services. These include the instalment dispensing of benzodiazepines, tri-cyclic
antidepressants, anti-psychotics, buprenorphine, and also the supervised
consumption of methadone mixture.
The overall objectives of the schemes are:
      To improve the consistency and quality of care to the client
      To ensure, as far as possible, that the client uses the methadone
       prescribed.
      To minimise the risk of harm to the client and to others.
      To improve communication between pharmacists, GPs, their clients and
       other named health care professionals.

Across all PCTs the SMMCP Schemes targets have been met or exceeded,
reflecting in a greater understanding of the clinical benefit of schemes such as
this and also the fact that targets have not been reviewed since the
commencement of most of the schemes in 02/03. Clearly this has an effect
financially and as such is being discussed in the relevant contract meetings.

In Hounslow the need for a dedicated coordinator to manage this growing
service has been recognised resulting in the management of the SMMCP
Scheme across Hounslow being devolved to the SMS Primary Care Team from
April 2005.

In April 05 the new Pharmacy Contract was launched and will inevitably change
the way pharmacies provide community dispensing and health care with
emphasis being placed on increased clinical governance and uniformity of
service provision. Pharmacy Contract service outlines for supervised
consumption/dispensing in instalments have recently been released and will
direct PCTs on the future development of SMMCP Schemes nationally.
Interestingly contact from pharmacies interested in joining the SMMCP Scheme
has increased and this may be a consequence of the pending new Pharmacy
Contract.


                                       73
          (Fig 10.05) SMMCP Scheme: Pharmacist Registrations by Sector
          The number of Pharmacists registered on scheme against locally set targets.

                            SMMCP Scheme : Pharmacist Registrations by Sector
   25

   20

   15

   10

      5

      0
              Westminster              K&C               H&F         Ealing       Hounslow

 02/03             14                   10                9                             7
 03/04             18                   11                10                         10
 04/05             23                   12                11                         10
 05/06             23                   12                14                         10



          The % of pharmacies offering SMMCP across each borough for 2005/6 is as
          follows:

          Westminster       : 24.5%
          K&C               : 31.6%
          H&F               : 34.1%
          Hounslow          : 20.4%


          (Fig 10.06) SMMCP Scheme: Clients on Instalment Dispensing
          The number of clients receiving Instalment Dispensing.

                      SMMCP Scheme : Clients on on Supervised Consumption
          (Fig 10.07) SMMCP Scheme: Clients Installment Dispensing
700
600
500
400
300
200
100
  0
             Westminster              K&C            H&F            Ealing      Hounslow

02/03           256                   128             1
03/04           460                   101             1
04/05           637                   79             19
05/06           424                   58             32



          The number of clients receiving Supervised Consumption.


                                                    74
                      SMMCP Scheme : Clients on Supervised Consumption
1200

1000

 800

 600

 400

 200

   0
            Westminster         K&C                H&F           Ealing         Hounslow

02/03          208              104                  7                             63
03/04          433               70                  7                            112
04/05          734               73                49                              40
05/06          1018              35                277                            495




        10.3   Pharmacy Needle Exchange Schemes (PNX)

        The Primary Care Service provides Pharmacy Needle Exchange Schemes
        across Hounslow, Hammersmith & Fulham, Harrow, Kensington & Chelsea and
        Westminster.

        The PNX Schemes aims are to make available clean injecting equipment for
        substance users in the community. It is an exchange scheme and clients are
        strongly encouraged to return to the pharmacy used injecting equipment in the
        sharps bins provided.

        The overall objectives of the schemes are:
           To improve the accessibility of clean injecting equipment for intravenous
            substance use, the primary aim being to reduce the risk associated with
            intravenous substance use, particularly blood borne viruses such as HIV and
            Hepatitis.
           To provide access points for the safe disposal of injecting equipment, the
            secondary aim being to reduce the number of contaminated sharps
            discarded unsafely in the community.
           To provide information, to support safer substance use and safer sex.
           To provide information on substance misuse, Hepatitis, HIV/AIDS & related
            disease.
           To provide information on existing services useful to the intravenous
            substance user.

        The PNX data for end 04/05 began to show a trend of reduced
        needle/syringe/sharps bin distribution (in all but the Hammersmith & Fulham
        area) despite a pharmacy membership on schemes that is maintained or
        increased. It is not immediately clear why this is the case but it has been
        recognised as a national trend and has resulted in ongoing discussion within
        relevant local needle exchange fora. In 05/06 this appears to have now
        stabilised.

                                              75
Note : the national mean rate of needle/syringe/sharps bin returns is 33%.

In April 05 the new Pharmacy Contract was launched and will inevitably change
the way pharmacies provide community dispensing and health care with
emphasis being placed on increased clinical governance and uniformity of
service provision. Pharmacy Contract service outlines for PNX have recently
been released and will direct PCTs on the future development of such schemes
nationally. Initiatives are underway to improve data collection/improve service
provision across all needle exchange outlets starting in 05/06 with a national
mapping of current needle exchange service provision. Improved data collection
across needle exchange sites would enable service providers to monitor activity
such as distribution/returns more accurately across their own PCT as well as
neighbouring PCTs. For example, a low returns rate in a local PNX may be the
result of an unusually high returns rate in the nearby fixed site needle exchange
service. At the moment we have no way of formerly monitoring this.


(Fig 10.08) PNX Scheme: Pharmacist Registrations by Sector
The number of Pharmacists registered on scheme against locally set targets.



                      PNX Scheme : Pharmacist Registrations by Sector

  15



  10



   5



   0
        Westminster         K&C         H&F           Ealing       Hounslow   Harrow
02/03       10               6           6              8               8       8
03/04       11               7           9              8               8       8
04/05       12               8           10             8               9       8
05/06       12               8           10                             9       9



The % of pharmacies offering PNX across each borough for 2005/6 is as
follows:

Westminster       : 12.8%
K&C               : 21.6%
H&F               : 24.4%
Hounslow          : 18.4%
Harrow            : 15.8%

(Fig 10.09) PNX Scheme: Bin Distribution by Sector
The number of Sharps Bins distributed individually or through PNX packs



                                              76
                             PNX Scheme : Bin Distribution by Sector

30000


20000



10000


    0
           Westminster        K&C               H&F           Ealing      Hounslow    Harrow

 02/03                                                                                 6349
 03/04       27319            15188             844            439          2295       8271
 04/05       27100            10500            14948           105          2084       4350
 05/06       32558            9201             15966                        8884       4416




          (Fig 10.10) PNX Scheme: Bin Returns by Sector
          The number of Sharps Bins returned to outlets.

                                     PNX Scheme : Bin Returns by Sector

 15000



 10000



  5000



     0
            Westminster        K&C              H&F            Ealing      Hounslow    Harrow
  02/03                                                                                 444
  03/04        8752            5495             594             428          1753       993
  04/05       10571            6911             7221            114          1289       595
  05/06       14979            6481             4050                         3177       387



          The average PNX Bin return rates for each borough in 2005/6 are as follows:

          Westminster     : 46.0%
          K&C             : 70.4%
          H&F             : 25.4%
          Hounslow        : 35.7%
          Harrow          : 8.8%




                                                       77
    (Fig 10.11) PNX Scheme: Needle Distribution by Sector
  The number of Needles distributed individually or through PNX packs

                               PNX Scheme : Needle Distribution by Sector



 300000


 200000


 100000


         0
              Westminster       K&C            H&F           Ealing         Hounslow   Harrow
  02/03                                                                                63490
  03/04         273190         151880         81140          22290            30680    82710
  04/05         271000         105000         149480         8210             28030    49300
  05/06         325580          92010         159660                          88840    48578




   (Fig 10.12) PNX Scheme: Syringe Distribution by Sector
  The number of Syringes distributed individually or through PNX packs
                            PNX Scheme : Syringe Distribution by Sector



300000


200000


100000


    0
             Westminster       K&C            H&F           Ealing          Hounslow   Harrow

 02/03                                                                                 68000
 03/04         273190         151880         141480         72880            99390      9610
 04/05         271000         105000         149480         25770            93280     44740
 05/06         325580          92010         159660                          88840     43030




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