Customer insight workshop a steve rose

Birmingham Total Place Pilot Drugs and Alcohol Customer Insight Steve Rose – Birmingham City Council Simon Dickinson – Aperia Neil Mackin - CACI

Total Place Birmingham One of 6 themes. Also: mental health, learning disabilities, guns and gangs, early intervention, total community, leadership & governance; Drugs and alcohol: Drug recovery programme Reducing alcohol-related hospital admissions Alcohol availability and pricing Customer insight The emerging threads

Birmingham Total Place Moving beyond treatment to recovery: “ Unemployment, poverty, and homelessness make up the soup on which addiction and criminality feed. Work, prosperity and decent homes are aspirations which encourage abstinence and honesty” Paul Hayes, NTA Birmingham, Sept. 2009

Every £1 spent on treatment saves £9.50 in the criminal justice system Every £1 spent on recovery orientated treatment and community reintegration should save Birmingham considerably more Drug Recovery Programme

Alcohol: reducing admissions In Birmingham the equivalent of 1 hospital ward is occupied all year by patients suffering from alcohol specific conditions About 12 wards are taken up by patients with conditions which are linked to alcohol use to some degree One person was admitted 24 times in a year and cost £34,000 to treat Total hospital service cost in Birmingham is £5.7m

Steve Rose – Birmingham City Council Simon Dickinson – Aperia Neil Mackin - CACI Customer Insight IDeA Funded Project Drugs and Alcohol Customer Journey Maps and Recommended Pilots

Health Substance Services Public Services Emergency Services Justice Police BCC Drug & Alcohol Service Providers NHS Business Services Hospitals PCTs GPs Probation Prison DIP Arrest DAAT Crime Arrest Out of Hours Calls Fire Incidents DIP Referrals Opinion Survey Children (CareFirst) Housing (SX3) WMPHO BHWP Needle Exchange Commissioning Service Provider Commissioning Case Management Case Files Prescribing Data Aggregate Hospital Episodes Monitoring NDTMS Hospital Records Case Files for Patients A+E Admissions flagged for Substance Offender Assessment (OASys) Accredited Programmes (IAPS) Prison Records SPOC Call Centre Revs / Bens (Northgate) Adults (CareFirst) Public Health Mortality Files Courts Sentencing Records Mental Health Trust Drugs and Alcohol Data Map

Drugs - Demand The Consolidated Demand Index arising from Drugs Misuse: DAAT Needle Exchange Volumes - Pharmacy Level aggregated to Ward NHS Business Authority - Spend on prescriptions relating to Opiate Dependence Police Data - Drug Possession Offenders Probation Service OASys - Drug Offenders with Criminogenic Need Demographic Propensity - derived from ACORN profile of Drug Offenders

Drugs - Cost Consolidated Cost Index arising from Drugs Misuse: 1) Birmingham Opinion Suvey - Proportion who say that people using/dealing drugs in the local area is a big problem 2) Police Data - Instances of Drug Possession crime 3) HES Data - Inpatient Admissions for Drug Misuse

Alcohol Harm Department of Health Harmful drinking – high admission segments

Alcohol- Cost The Consolidated Cost Index arising from Alcohol Misuse. 1) Birmingham Opinion Suvey - Proportion who say that people being drunk or rowdy in the local area is a big problem 2) Police Data - Instances of ARV crime (Alcohol Related Violence) 3) HES Data - Inpatient Admissions for Alcohol Attributable Reasons

Service Journey Measures operations e.g. throughput Not have we achieved what the customer wants

Drug Workshop Hopes and Fears Their aggregated journeys What does the system look like What would they change Circles of Need® - all content is © Aperia 2009

Drugs – Hopes and Fears DRUGS Not getting treatment Wish my past would stop being brought up by the same people in social services (people can change). The past is what w e are trying to move on from JOBS To get out of Birmingham and get a good life Get a girlfriend & job with a good wage Not becoming an addict again To get a car Not being funded to get a tier 4 place Not getting the help you need To have enough money To be abstinent from all substances – legal and illegal Of a lapse and taking an overdose and dying from it I am going to rehab. I just hope I can complete and get to be drug free and start living my life again Of staying in Brum and leading the same life as the last 20 years – and no job Treatment plan / centre not equipped for my needs Day care centre to run for 6 months – it is only 3 now My past being constantly brought up That things change in the right places To fail and be on drugs for the rest of my life People to better understand rehabilitated users Family and friends finding out you are on drugs When someone is not prepared to listen To get my own flat To regain contact + build relationships with loved ones To get fitter / more active Being in the wrong place at wrong time and end up using Relapse into drug abuse Help other people like me help themselves To receive help + treatment from services Having too much money to spend on wrong thing To gain qualification through service provider To become valued member of society That I’ll be judged on my past Will never be able to get into a well paid job again Wont be able to gain employment because of my past

DRUGS Not getting treatment Wish my past would stop being brought up by the same people in social services (people can change). The past is what w e are trying to move on from JOBS To get out of Birmingham and get a good life Get a girlfriend & job with a good wage Not becoming an addict again To get a car Not being funded to get a tier 4 place Not getting the help you need To have enough money To be abstinent from all substances – legal and illegal Of a lapse and taking an overdose and dying from it I am going to rehab. I just hope I can complete and get to be drug free and start living my life again Of staying in Brum and leading the same life as the last 20 years – and no job Treatment plan / centre not equipped for my needs Day care centre to run for 6 months – it is only 3 now My past being constantly brought up That things change in the right places To fail and be on drugs for the rest of my life People to better understand rehabilitated users Family and friends finding out you are on drugs When someone is not prepared to listen To get my own flat To regain contact + build relationships with loved ones To get fitter / more active Being in the wrong place at wrong time and end up using Relapse into drug abuse Help other people like me help themselves To receive help + treatment from services Having too much money to spend on wrong thing To gain qualification through service provider To become valued member of society That I’ll be judged on my past Will never be able to get into a well paid job again Wont be able to gain employment because of my past Hope I can get off drugs, but fear I might not Fear that treatment wont work for me Hope I can get a job and a life Past may stop me getting a job To be given a chance to move on Break away from Birmingham Give something back What others think of me Drugs – Hopes and Fears

Parents send me to Brum – stayed clean for 18 months Several drugs services experiences in diff places – usually positive I self-referred to Azaadi and havent looked back Had very good care from mental health Counsellor Azzadi has been a great help to me Pregnancy – went to GP who referred me into mother+baby Forced into detox in Dublin (or kids taken away) Self-referral thru’ parents DIP referral worked well for me Mother+baby team helped me get clear before – excellent dedication of team DIP housing good – got my flat Good relationship with my drug worker I got clean and felt positive and happy in prison for 8 months Found 12 step was very beneficial – 9months gave me long enough to find a new way to live without drugs Referral by DIP was the start DIP worker was brilliant Phoenix futures, day structure – helped me with new skills+tools (but not child friendly) Safe proj and Anawim – support me with everything Mum passed away – self referral into Azzadi Addaction – very positive and good follow-up Threats again to take my kids Day care services give u structure and something to do Methadone helps in that can survive without stealing DRUGS – What helped?

Parents send me to Brum – stayed clean for 18 months Several drugs services experiences in diff places – usually positive I self-referred to Azaadi and havent looked back Had very good care from mental health Counsellor Azzadi has been a great help to me Pregnancy – went to GP who referred me into mother+baby Forced into detox in Dublin (or kids taken away) Self-referral thru’ parents DIP referral worked well for me Mother+baby team helped me get clear before – excellent dedication of team DIP housing good – got my flat Good relationship with my drug worker I got clean and felt positive and happy in prison for 8 months Found 12 step was very beneficial – 9months gave me long enough to find a new way to live without drugs Referral by DIP was the start DIP worker was brilliant Phoenix futures, day structure – helped me with new skills+tools (but not child friendly) Safe proj and Anawim – support me with everything Mum passed away – self referral into Azzadi Addaction – very positive and good follow-up Threats again to take my kids Day care services give u structure and something to do Methadone helps in that can survive without stealing Self-referral, parents played a role (death or force) 12 step Methadone Individual key worker was the key Its the service that counts Clean in prison Pregnancy and my parents DRUGS – What helped?

Job Centre – didnt help Summerhill terrace – RRAT dont treat individual Moving from JSA to ESA can be frustrating Methadone Came out of DIP – not enough support DIP East – no follow up around relapse control Government owned services are less capable Chest infection – got codeine and started to seek drugs again Waiting to go to Mum+Baby rehab – delayed by child+fam Doctors dont listen and seem to want control. They are happy to keep you on script for as long as possible Getting back with other users Aftercare coming out of prison was poor. Worked hard for 3.5yrs, but no support Rehab was forced on me – I wasn’t ready for it Doctors don’t want to cut down meths Found other people using drugs (went looking for them) Waiting time after DIP is too long Other things other than methadone (morphine, pills/amps, Df118s) Too much free money – unlikely to get job that will pay enough to make it worthwhile Give a straight detox in prison Swansell – drug worker changed, things went downhill Prison was too easy – no deterrent, not enough help from CARAT team Prison – lack of help from drug services, no rehab Social services – tried to take kids and then dropped me No dry houses for women Penalised if you have kids Workers in the system get moved around – not enough professionalism DRUGS – What hindered?

Job Centre – didnt help Summerhill terrace – RRAT dont treat individual Moving from JSA to ESA can be frustrating Methadone Came out of DIP – not enough support DIP East – no follow up around relapse control Government owned services are less capable Chest infection – got codeine and started to seek drugs again Waiting to go to Mum+Baby rehab – delayed by child+fam Doctors dont listen and seem to want control. They are happy to keep you on script for as long as possible Getting back with other users Rehab was forced on me – I wasn’t ready for it Doctors don’t want to cut down meths Found other people using drugs (went looking for them) Waiting time after DIP is too long Other things other than methadone (morphine, pills/amps, Df118s) Too much free money – unlikely to get job that will pay enough to make it worthwhile Give a straight detox in prison Swansell – drug worker changed, things went downhill Prison was too easy – no deterrent, not enough help from CARAT team Prison – lack of help from drug services, no rehab Social services – tried to take kids and then dropped me No dry houses for women Penalised if you have kids Workers in the system get moved around – not enough professionalism Back with wrong people Methadone and the way it is prescribed DRUGS – What hindered? Waiting for rehab – not enough space Aftercare coming out of prison was poor. Worked hard for 3.5yrs, but no support Flexibility in prison ?- support after More help coming out of DIP Waiting – rehab, mother/baby and after DIP Changed worker Codeine for chest Relats and frustrations with benefits Govt owned services less good What’s my incentive? RRAT not individual Not ready for rehab Social services and families

Alcohol Workshop Their aggregated journeys What does the system look like What would they change

Example Journey’s Tightrope/balancing act It’s a roll of the dice Disaster awaits, perhaps feels inevitable

Example Journey’s The clock is ticking… … is time running out No chances, ‘dark clouds’ There is a ‘system’ but hard to break into it With barriers along the way

Customer Journeys Ups and downs of the customer experience Key journey steps Agency Touch-points 1991 2000 2008 2010 Suicide Attempt, A+E Admission Relapsed upon release from hospital Suicide Attempt, A+E Admission Relapsed upon release from hospital Suicide Attempt, A+E Admission; detoxed Relapsed upon release from hospital Medication treatment from GP Off sick with depression Started drinking JD with current partner who's alcohol dependant Arrest and sent to hospital due to sickness and shakes Forced 9 day Detox Social Services Intervention around child 1st session; Search for activities (dance) 2nd session Book appointment at GP for depression Argument with Neighbours Relapsed over weekend Controlled drinking; Abuse from neighbours ongoing; Seeking help from Housing Seek additional support for son Arrange transfer meeting Child in Need meeting with Social Worker Depression Unsure if employer support her Depression – drink to cope with life Depression Humiliated Motivated to sort life out Worried about son’s care Hospital Hospital Hospital GP Police Hospital Alcohol Services Social Services Education Housing 38 yrs old. Female, Lives with 7yr son Older 18yr son who’s left home 2005 Drank with friends at home; family drink dependent Caught in Abusive Relationship Argument with rowdy neighbours who stop her sleeping after night shifts Alcohol Services Social Services Alcohol Services Social Services

Initial Views – the system No clear shared understanding across the system of what works and what doesn’t work No clear relationship between customer outcomes and service measurement / management No visibility of performance across the stakeholders and no Risks and benefits are not shared across partners Users believe there is a system, but providers / stakeholders do not perceive a system Very heavy skew towards tier 3 – only about 5% is spent on prevention Reliance upon fixed cost resource solutions, rather than networking, training and information No pathways Very service and contract placement led

Initial Views – customers Using Advocate as a gateway to long-term recovery planning and broader into public-service More flexibility in service consumption – allowing users to design recovery pathway One size doesn’t fit all More aggressive reduction from methadone (drug-free wings in prisons?) Encouraging more service user leadership and self support (alcohol) Time / target interventions around life events such as bereavement, child-birth and family break-up “ Use my fear / pain” Earlier referral into the system – by GPs, Adult Social Care, Housing Use initial contacts to build relationship, rather than “fast-track” Evidence base for controlled drinking

The True Cost of Drugs in Birmingham – Per Annum Benefits Hospital Admissions Criminal Justice System Other Spend DAAT £27.8m £33m £15m £2.3m £??m

Drug Treatment Provision £3.7m £1.08m £3.4m £15.6m £1.4m Police Adult Social Services GPs Families Schools Mental Health Trust Acute Trust Probation Prisons Housing Single Point of Contact DATUS Peer-led Advocacy DIP (BCC) DIP (ARW) Needle Exchange Outreach Inreach Addaction DIP CARAT Midland Heart SADIE KIKIT BBV Community Outreach GP Prescribing CDT/DIP Prescribing Swanswell Turning Point Safe project EESPro DRR Mother & Baby Residential Rehab Detox Structured day care Professional Self referral Advisory Tier 1 Tier 2 Tier 3 Tier 4 Pooled Treatment £13.1m Drug Intervention Programme £5.3m Birmingham City Council £1.3m PCTs £5.6m Other £357k DoH Tier 4 Grant £1.3m

Alcohol Treatment Provision £??? £170k £1.2m £2.4m £738k Social Service GPs Housing SPOC YOT Self Referred Probation Police Community Alcohol Team Mental Health Trust Acute Trust Freephone Pharmacy Support Services Alcohol Concern Self Help Sessions (NACRO & RAPT) GP Screening Community Support Sessions BNE Erdington Outreach Worker Norman Imlah Centre Arrest Referral Scheme Primary Care Services (alcohol workers in GP clinics Alcohol workers in hospital wards Aquarius Birmingham & Solihull Mental Health Foundation Trust In-patient detox and rehab services Professional Self referral Advisory Tier 1 Tier 2 Tier 3 Tier 4 PCTs x 3 £3.8m Safer Birmingham (ring fenced) £250k Birmingham City Council £500k

Summary Findings Limited insight into what works and what doesn’t work No shared visibility of performance Service / contract system, not focused on outcomes Does system drive cyclical dependency? – less than 5% is spent on prevention We control the money…..No customer insight or control over service consumption Budgets don’t relate to need, drugs disproportionately greater than alcohol funding

Drug/Alcohol assessment against TP principles Shared clarity of objectives  Health and Crime engaged  Minimal input elsewhere Performance measuring against genuine outcomes  Totally lacking Pooled budgets  For treatment  Not for prevention Shared responsibility and accountability for outcomes  NI indicators for LSP  Limited cascade to drive outcomes Joined-up commissioning of services  For treatment  Not for prevention Services wrapped-around customer needs  Health management focused, not need or outcome driven Sharing of information  Parochial record keeping, is this in the customers’ best interests Personalised for efficiency and effectiveness  Limited, predominantly one-size fits all

Key Recommendations – Drugs and Alcohol Make sustainable and incremental improvements in Drugs and Alcohol services, moving towards Total Place approach Establish outcome tracking and service demand Drive transformation through a number of pilots Undertake review and tightening of all contracts and the DAAT operation

Service Redesign Pilots Ideas….

Future System? Strategic assessment of Service Demand and Provision Insight into location, volumes and people’s wider Prevention Service Provision Emerging Need Severe or Acute Need Baseline Evidence Targeting Monitoring Pilots

Advocates to Join Up Services toward Desired Outcomes Keyworker as advocate to broadest service offering Increase Efficiency and Effectiveness of Service Delivery Shorten treatment cycles by addressing contextual factors Benefits Effort Mis-users bounce around the public sector with great inefficiency and ineffectiveness Sorting out their wider issues helps address their substance mis-use problem Prevent Detect (incl. CJS) Treatment Positive Outcomes Present Future

Social Media Support Network Benefits Effort Commissioning on Outcomes e.g. Bonus for anniversary of positive outcomes Reducing payments for very long term clients Social Media Self-Help Mutual support network for the alcohol mis-user community Reduced dependency based service cost Prevent Detect (incl. CJS) Treatment Positive Outcomes Alcohol misusers develop dependency on Tier 3 service consumption Long term clients absorbing too much resource Present Future

Self Directed Personalised Support - drugs Failed treatment cycles Lack of personalisation Reduced ownership Benefits Effort Increase ownership and reduce number of failed cycles Self design packages of support Prevent Detect (incl. CJS) Treatment Positive Outcomes Present Future

Service Redesign Pilots Advocates to Join Up Services toward Desired Outcomes Social Media Support Network - alcohol Self Directed Personalised Support - drugs Life Event Triggered Interventions around Customer Need Local Commissioning to Drive Service Efficiencies Local Culture Change to Drinking

Next Steps Total Place Continues Progress ‘Birmingham Budget’ 5 principles Transformation Prevention Personalisation Collaboration Self sufficiency / reduced dependency Specific to Drugs and Alcohol Drugs – “In Control” Manage change and design how to make flexibility an intrinsic part of the ‘system’. Alcohol – Social Media

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