customer insight workshop a steve rose

Birmingham Total Place Pilot

Drugs and Alcohol Customer Insight

Steve Rose – Birmingham City CouncilSimon Dickinson – AperiaNeil 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, NTABirmingham, 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


Customer Insight IDeA Funded Project Drugs and AlcoholCustomer Journey Maps and Recommended Pilots

HealthSubstance 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

BHWPNeedle Exchange Commissioning

Service Provider Commissioning

Case Manageme

nt 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

The Consolidated Demand Index arising from Drugs Misuse:

1) DAAT Needle Exchange Volumes - Pharmacy Level aggregated to Ward

2) NHS Business Authority - Spend on prescriptions relating to Opiate Dependence

3) Police Data - Drug Possession Offenders

4) Probation Service OASys - Drug Offenders with Criminogenic Need

5) Demographic Propensity - derived from ACORN profile of Drug Offenders

Drugs - Demand

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

Drugs - Cost

Department of Health Harmful drinking – high admission segments

Alcohol Harm

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

Alcohol- Cost

Service Journey

DannySEGEMENT:- Drug AddictGENDER:- MaleAGE GROUP:- 25-40RELIGION:- n/aSTATUS:- SingleDEPENDANTS:- 1 child

DannySEGEMENT:- Drug AddictGENDER:- MaleAGE GROUP:- 25-40RELIGION:- n/aSTATUS:- SingleDEPENDANTS:- 1 child

How do we measure his outcomes?

How do we measure his outcomes?

Measures operations e.g. throughputNot 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 14

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

Drugs – Hopes and Fears

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 flatTo 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

againWont 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 flatTo 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 jobTo be

given a chance to move on

Break away from Birmingha

m

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

CounsellorAzzadi 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

CounsellorAzzadi 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 supportDIP 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 teamPrison – 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 supportDIP 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 teamPrison – 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 DIPWaiting –

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

rehabSocial services and families

Alcohol Workshop

• Their aggregated journeys

• What does the system look like

• What would they change

21

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 itWith barriers along the way

Customer JourneysU

ps a

nd d

owns

of t

he cu

stom

er e

xper

ienc

e

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


Suicide Attempt, A+E Admission; detoxed


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 PoliceHospital

Alcohol Services

SocialServices

EducationHousing

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

SocialServices

Alcohol Services

SocialServices

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

25

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

26

The True Cost of Drugs in Birmingham – Per Annum

Benefits Hospit

al

Admiss

ions

Criminal Justice

SystemOther Spend

DAAT

£27.8m

£33m

£15m

£2.3m

£??m

Drug Treatment ProvisionPooled

Treatment

£13.1m

Drug Intervention Programme

£5.3m

Birmingham City Council

£1.3m

£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

PCTs

£5.6m

Other

£357k

DoH Tier 4 Grant

£1.3m

Alcohol Treatment Provision

PCTs x 3

£3.8m

Safer Birmingham(ring fenced)

£250k

Birmingham City Council

£500k

£??? £170k £1.2m £2.4m £738k

•Social Service•GPs•HousingSPOC•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

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 principlesShared 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 assessme

nt 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 MonitoringPilots

HealthSubstance 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

BHWPNeedle Exchange Commissioning

Service Provider Commissioning

Case Manageme

nt 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

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 Outcomese.g.

• Bonus for anniversary of positive outcomes• Reducing payments for very long term

clients

Social Media Self-HelpMutual support network for the alcohol mis-user community

Reduced dependency based service cost


• 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


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

Birmingham Total Place Pilot

Drugs and Alcohol Customer Insight


customer insight workshop a steve rose

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