To review the quality and performance of the substance misuse service commissioned by Herefordshire Council and delivered by Addaction.

A presentation was given by officers of Addaction.

In his introduction, the chief officer of Addaction thanked council officers for their frank feedback and noted concerns raised about service delivery which he had taken up with Addaction’s trustees.  An action plan had been discussed with the public health team and it was recognised that the service had not started-off well and that the resulting concerns were understood. It was accepted that the level of cultural change was underestimated, and with support, the service had now identified what was required to make the transition from a medical model of care to one that was more peer and community focused.  Much had been learned from this and there was confidence that the team was in place to take the service forward.  The motivation was to ensure the best possible service for Herefordshire, regardless of who provided the service. 

In answer to a member’s question about what the challenge was in taking on the Herefordshire service compared with other areas that Addaction covered, the chief officer explained that there were demographic challenges in Herefordshire with implications for an available workforce.  A possible comparative area was Norfolk but in Addaction’s experience there were very few close comparators to draw upon. Other factors were that the shift in service model was greater than had been seen with other services whilst ensuring continuity for service users.  There had been much learning taken from this area and a different approach was being taken to recruitment and training.

Members welcomed the invitation to visit Addaction again and for the opportunity to hear from a service user about their experience of the service.

A member asked about cultural changes, staff transfers and recruitment in terms of how long it would now be expected to take, with the benefit of lessons learned, to make the transitions required and embed the new model of provision.  In response, it was estimated that this would take 6 to 9 months.   In terms of preparation for re-tendering within a 3 year contract, it was believed that the best approach was to ensure the service continued to evolve right up to point of re-tendering and that the next transition for the new contract would be smoother as the most challenging aspects of service development had been overcome.  Contracts tended to be of 3 years’ duration typically although longer terms were emerging nationally, and recent research had shown how contracting could affect service delivery.  It was noted by the Director of public health that the new drugs strategy recommended longer contracts although this could be a challenge for funding with the public health grant ending in 2019 and arrangements thereafter remaining unclear.

A member asked about patterns of substance use. Officers suggested that patterns were linked to changes in the drugs market and how the supply chain operated within rural areas compared with urban areas. The impact of police intervention was known to interrupt supply which then resulted in a down turn in use of particular substances. 

The Addaction service manager for Herefordshire explained how the culture of the service was changing. This included a move towards group work and peer involvement where previously the service was based on 1-1 transactional support. The focus was now on structured group work which supported a clearer pathway for staff and service users. Within this there was flexibility in recognition that 1-1 or smaller group working was sometimes more appropriate to an individual’s needs.  Recovery support was provided by staff and peers and there were a number of activity groups for service users to take part in.  The approach was built upon enabling ideas and challenges to be shared between peers, which was shown to be a stronger approach.

A member wondered if this approach could have been introduced from the start of the contract. In response, the service manager commented that these changes required the staff to be ready to support the approaches, enabled through secondments from other services familiar with the models and providing ongoing training.  There were also new staff who were joining with fresh ideas and experience and although it had been difficult to recruit to Hereford there was just one vacancy remaining. There was also evidence of how the service was supporting service users to come through recovery by becoming members of the team.

Responding to a question regarding improvements made following Care Quality Commission (CQC) inspections this year, it was explained that there were some improvements in records management although there remained both paper and electronic records. The CQC had found significant improvements in risk assessments, which were now at 97% completion, and care planning had improved. Further improvements were to be addressed through training. 

The vice-chairman noted that the Addaction service had been present in Leominster for a year and some good work had been seen. He asked about any plans for increased engagement with the community, noting that there had been some local alcohol-related issues. The service manager welcomed the opportunity to meet with members in Leominster to discuss local matters.  It was noted that the team in Leominster was slightly smaller and so service users were able to access the Hereford-based provision in addition. Community links were being developed and there was a co-production panel established which involved other services and businesses in shaping the local provision and contributing to resources to support service users.

In response to a member’s question about support for family members, the service manager clarified that it was intended to extend family support groups with the involvement of the co-production panel. There had also been constructive discussion with Carer’s Support to enable their presence in the service to support family members.

As regards outreach to schools, there was a young people’s team in touch with all schools and colleges, attending workshops and community events and taking referrals. A list of the schools the service planned to visit in the next 12 months was requested. 

A member asked about what Addaction did to reach people given the county’s significant rurality. The service manager confirmed that the service understood the complexities of rurality and explained that the service intended to build capability around communications and information technology as well as exploring potential premises where staff presence could be extended. 

The matter of variable broadband coverage was noted as a requirement to consider other methods of communication in more isolated areas about how to access support such as advertisements in public and community facilities. 

In terms of a plan to address outreach in rural areas, this was in development, taking good practice from other areas and building on the approach and development of the communications aspects such as signage and appropriate locations.  

The Healthwatch representative welcomed the engagement between Healthwatch and Addaction. She noted the holistic approach taken by Addaction and commented on the value of local health service providers’ involvement in discussions as mental and physical health were part of the complex issue of addiction, and that it was regrettable they were not present today. 

The service manager commented that this method of working was welcomed and there were links with 2gether NHS Foundation Trust to develop pathways for people to have the right level of service. 

Members requested the routine attendance of health providers at committee meetings, and the advice was noted that 2gether could not be represented at the meeting today as intended.

It was noted that there were plans to develop the legal relationship between Gloucestershire Care Services NHS Trust and 2gether NHS Foundation Trust, with the intention of their merging as one provider, to take effect in 2018. The director for adults and wellbeing pointed out the overlapping of client groups between such organisations and this would be an emerging model across the region which would promote the sustainability of these often smaller providers. It was noted that as 2gether was the mental health service provider for Herefordshire, although the majority of its operation was within Gloucestershire, a watching brief on developments in this matter was recommended.

Addaction’s chief officer provided a more detailed response to an earlier question regarding the use of opiates and the relationship with e-cigarette devices (‘vaping’), having obtained up to date information. In explanation, there were a number of local pictures rather than a national trend and the cohort of opiate users was experiencing differences around broader physical health. Usage was fairly stable, but the methods of use were changing and some substances were harder to track; there was some decrease in usage noted as a response to unemployment, labour market trends and supply. In terms of ‘vaping’, information obtained from the Advisory Council for Drugs suggested that e-cigarettes were more likely to be used for synthetic cannabinoids rather than opiates, although there was no noted prevalence currently.  The member suggested that the situation be monitored.

RESOLVED

That

(a)        a service update be provided to the committee in early 2018;

(b)       opportunity be provided for a service user’s experience of Addaction to be shared with committee members; and

(c)        consideration be given by commissioners to contracting services for 5 years, with a mid-term review, to support the embedding of effective service provision.