Making Sense of Complex Need in the Treatment of Drugs and Alcohol Dependance and Misuse.

Alec Fraher and Associates Ltd copyright@2006

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Introduction

Making sense of complex need is difficult for two reasons. Firstly, the nature of need is determined by the person as patient, social care/social work client and as consumer. It also requires a distinction between duties owed to the individual and their family and a target duty to a defined population of people with a similar need for help. It may mean both this is difficult territory - as the range and type of needs where duties apply are located in different legislation, regulations and guidance.

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Introduction

Secondly, the NHS and Social Care reforms, have since the mid nineties required that a new mix of service providers are engaged in this task. Since 1993 the direction of travel has encouraged the use of private and voluntary sector providers as bought-in alternatives to in-house provision. The primary task of social work is assessment and co-ordination.

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Introduction

Since 1998 the emphasis has been on the development of collaborative models of care. The aim is to break down barriers between services and ensure that networks of innovative primary care services are provided in a coordinated way and are user friendly. Models of Care (MoC) for drug users was introduced in 2004; Models of Care for Alcohol has recently been introduced. Both MoC and MoCA are bespoke versions of other NSFs used for other adult customer groups All versions of models of care advocate the whole system approach for assessing the health and social needs of people.

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Defining Need: Patient First?

Can we define complex patient need? Are diagnostic definitions of complex patient need compatible with other definitions of need?

What role is played by which professional and is it effective?

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Can we define complex patient need?

Defining complex patient need requires a skilled professional judgement to be made against the criteria set out in ICD10. Co-morbidity or differential diagnosis are also set out in ICD10. It is complex because the interaction between a treatable condition, the pre-morbid personality and life situation demands an integrated approach from highly skilled professionals. These types of diagnosis are usually the responsibility of a consultant psychiatrist 03/10/2013 working as part of a multi-disciplinary team 6

Are diagnostic definitions of complex patient need compatible with other definitions of need?

The term complex patient need is not a recognised legal concept, although the existence of a medical condition, complex or not, underpins the legal concepts.
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Definitions of need

The legal terms are: Assessment of Need; Duty to Assess Need and; Third Party Assessed Need Other concepts such as vulnerability, active/passive supervision, frequency of and prolonged attention during the day/night are, subject to interpretation, related legal concepts.

Each legal concept is underpinned by the existence of a medical condition or special circumstance.

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Definitions of need

There are also other categories of need ie individual need and targeted need. The latter is properly known as a target duty. Felt need is a need(s) as expressed by a service user and/or carer and has gained in increasing importance because of its human rights implications and the move towards Direct Payments and personalised budgets. The overall responsibility for assessing need as described above rests with the Local Authority This means the Corporate Authority as well as the Adult Services Directorate of a Local Authority

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Definitions of Need

In most instances the Duty to Assess and Meet Need for problematic substance users is a Target Duty Target Duties are not concerned with meeting individual or patient need but addressing the relative needs of the PDU/PDS population as a whole
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Definitions of Need

The implications of this are:

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Definitions of Need: The Implications

The needs of an individual patient or service user are assessed by reference to the arrangements made to meet the needs of the PDU/PDS population as a whole AND

the allocation of resources to meet the needs of the PDU/PSU population as a whole have traditionally been targeted at those with a diagnosed patient need
AND The role and responsibility for diagnosis rests with Psychiatry

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Definitions of need: The Implications However:

Where there exists an urgent need for continuing patient health care, Local Authorities (not necessarily Adult Services) and Health Authorities are required to set up schemes which are designed to meet the ongoing medical need. In this scenario schemes/programmes/services can be bought-in from the Independent Sector or be jointly provided by a mix of providers.
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Definitions of Need: The Implications

It also means that services identified as needed can be provided by one service but funded by another. However

This DOES NOT alter the statutory duties to assess individual need.
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Definitions of Need: The Implications

The assessment of individual need is NOT the same as assessed patient need UNLESS it is supported by a delegated powers scheme usually between the LA, NHS Trust and where required Probation AND Individual and/or patient needs assessed by a voluntary sector provider that are NOT supported by a delegated powers scheme may not be recognised as an assessment of individual need.

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Definition of Need: The Implications

AND

Unless there exists a delegated powers scheme Local Authorities may be in breach of their Duty of Care obligations, this is especially so where the target duty is underpinned by a duty to the individual.

AND
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Definition of Need: The Implications

A duty is owed to the individual when the assessor determines what is needed to preserve or restore normal living The eligibility criteria has been simplified and states that Councils should operate just one eligibility criteria, namely Should people be helped or not? And if so to what extent?
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Definitions of Need: The Implications

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Resource allocation matching the assessed needs of a targeted population as a whole and the numbers of people requiring an individual assessment of need ensures that in urgent cases the provision of services becomes first and the assessment second, this is necessary when meeting emergency or urgent patient need.
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Definitions of Need: The Implications

BUT

In any and all events the individual assessment of need and the patient assessment of need should be carried out by specialist assessors.

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Where does this leave us?

The arrangements made for meeting population need are known as Target Duties The Adult Treatment Plan and MoC and MoCA bring this to life. Target Duties must address the responsibilities for meeting individual and patient need.
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Where does this leave us?

The responsibility for assessing an individuals need for social care rests with Local Authority social workers, who should not be involved in the provision of services. Medically assessed need for continuing or urgent patient care can be met by an NHS provider or independent sector provider
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Where does this leave us?

BUT Unless assessed patient need is supported by a delegated powers scheme it is not recognised as an assessment of individual need. However In urgent cases of patient need, meeting the social care aspects of a medical condition is permitted while the individual assessment of need is completed.
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Where does this leave us?

Target Duties allow for the setting up of schemes to address all of the above BUT Do not replace the statutory obligation to assess the social care needs of an individual.
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Where does this leave us?

So. How do we know who will need an individual assessment of need?

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Client First: Individual Assessments of Need

Circular LAC(92)12, Housing and Community Care Requires that assessments focus on the difficulties an individual and carer is facing and take account of the following:
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Client First: Individual Assessment of Need

Capacity/incapacity Preferences and aspirations

The living situation

Support from family and friends Other sources of help
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Client First: Individual Assessments of Need

The assessment should look at the autonomy of the service user, their ability to fend for themselves and manage daily routines, including their family life and relationship with their community. The assessment must take account of all the relevant facts, like the views of the GP or other sources of help
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Client First: Individual Assessment of Need

Circular LAC (2002)13 Fair Access to Care Services advocates that the need for help can be banded into four categories: Critical Substantial Moderate Low
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Client First: Individual Assessment of Need

The banding system is a MUST DO approach to addressing the problems an individual has. However

It is for the Council to decide what MUST be done

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Client First: Individual Assessment of Need

It would be usual to consider a threat to life, acute health problems, chronic self abuse/neglect and significant harm to self or others as critical And The known susceptibility to the above as substantial.
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Client First: Individual Assessment of Need

Substantial need can also arise simply because the person or their family are overwhelmed by the volume of problems being faced and can not see a way out of them. In these circumstance the sum total of the difficulties are weighed against the ability of the person or their family to problem solve, with help.

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Client First: Individual Assessment of Need

Moderate Need is usually where the sum total of the difficulties being faced are not insurmountable but the person or their family are in crisis and would benefit from crisis counselling and brief interventions. Low Need is usually where the difficulties are about securing practical changes or arrangements to address a clearly identified problem area.
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Client First: Individual Assessment of Need

Circular LAC(93)2 states that people with serious and urgent alcohol and drug problems are likely to need a rapid response as deterioration may carry social, legal and care implications LAC(93)2 makes clear that where assessments are undertaken by third parties that they are aware of other needs for which the Local Authority has responsibility.
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Are Patient Assessed and Client Assessed Need Compatible?

Both depend on the resources of the individual (patient or client) and the extent to which they or their family can manage a medical condition in a way that is normal for them

Both assess the risks of interfering with a persons autonomy when making clinical or other professional judgements Both are concerned with increasing and/or maintaining the independence of the person, their family or carer.
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Are Patient Assessed and Client Assessed Need Compatible?

However Patient need is usually differentiated by 3 levels of need/service Expert Patient Programmes and Carer Support Complex Case Management Programmes Dependency Case Management Programmes
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Are Patient and Client Assessed Need Compatible?

Expert Patient Programmes are aimed at patients who can, with supportive help, look after themselves and can learn to manage their dependency Complex Case Management Programmes are aimed at those whos personalities make it difficult for them to get help and require case management. AND

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Are Patient Assessed Need and Client Assessed Need Compatible?

Dependency Care Management Programmes, aimed at patients with high health risks requiring a proactive condition management programme. For example, during and after pregnancy; or because of the risks of liver damage/failure; or are TB, HIV, Hep B or Hep C symptomatic; or where treatment for DVT requires the introduction of a withdrawal programme in an acute hospital setting, and so on. In these scenarios it is likely that trauma support and high-level specialist intervention will be required from both medical and psychotherapeutic services, including family therapy.
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Are Patient Assessed Need and Client Assessed Need Compatible

Applying Circular LAC(92)12 and LAC (2002)13 to each the three levels of patient need is an option Although the provisions made under

LASSA 1970 s7E(b) as amended by s50 NHSCCA 1990 and (Alcohol or Drug Misusers) Directions 1990, Circular LAC (93)2, the HA 1999 and HSCA 2001
advocate the setting up schemes for this patient/client group
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Are Patient Assessed Need and Client Assessed Need Compatible?

However The provisions made by way of a target duty are only viable should they also meet any of the duties owed to the individual by virtue of their eligibilty under other schemes.

This applies to the following groups

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Priority Groups

Those who are HIV symptomatic or who present with other severe physical comorbidity

Those with mental co-morbidity, including personality disorder Pregnant women and nursing mothers, and in some cases their partners
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Other priorities can include:

Patients where there are child protection issues Chaotic and long term injectors and those with cognitive impairment arising from alcohol misuse Offenders on court orders
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Consumers First

The primacy of public procurement and competition law over social protection and social welfare law has radically and irreversibly alter the terrain. It is a matter of time until all services offered to this population will be considered as a third party assessment and not fall within the routine work undertaken by LAs and CCGs. It may take another 10-20yrs for the socio-legal ogligations owed to the individuals and their families to fall within the scope of the OFT and subject to Unfair Terms and Conditions Act.

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What This Means

In short. Nobody Knows. The NHS and Social Care Act 2012 has ushered in a requirement for the handling of Super Complaints. But no mechcanism exits to do this.

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Next Steps
1.

2.

3.

Seek permission from the SoS for Health for an EC Article 168 exemption from the unckecked use of competitive processes. Adopt a known approach to assessing service viability, like Vaible Systems Modelling Ensure that a public service ethos can be demonstrated.
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