making sense of complex need

7/27/2019 Making Sense of Complex Need

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Making Sense of Complex

Need in the Treatment of Drugs and AlcoholDependance and Misuse.

Alec Fraher and Associates Ltdcopyright@2006


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IntroductionSecondly, the NHS and Social Care reforms, havesince the mid nineties required that a new mix of service providers are engaged in this task.

Since 1993 the direction of travel has encouraged theuse of private and voluntary sector providers asbought-in alternatives to in-house provision.

The primary task of social work is assessment andco-ordination.


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Since 1998 the emphasis has been on the development of collaborative models of care. The aim is to break down barriersbetween services and ensure that networks of innovativeprimary 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. BothMoC and MoCA are bespoke versions of other NSFs used forother adult customer groups

All versions of models of care advocate the whole systemapproach for assessing the health and social needs of people.

Introduction


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Defining Need: Patient First?Can we define complex patient need?

Are diagnostic definitions of complexpatient need compatible with otherdefinitions of need?

What role is played by whichprofessional and is it effective?


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Can we define complex patient

need?Defining complex patient need requires askilled professional judgement to be madeagainst the criteria set out in ICD10.Co-morbidity or differential diagnosis are alsoset out in ICD10.It is complex because the interaction betweena treatable condition, the pre-morbidpersonality and life situation demands anintegrated approach from highly skilledprofessionals.These types of diagnosis are usually theresponsibility of a consultant psychiatristworking as part of a multi-disciplinary team


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Are diagnostic definitions of complex patient need compatible

with other definitions of need?

The term complex patient need isnot a recognised legal concept,

although the existence of a medicalcondition, complex or not,underpins the legal concepts.


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Definitions of needThe 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 medicalcondition or special circumstance.


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Definitions of needThere are also other categories of need ie individual need andtargeted need. The latter is properly known as a target duty.

Felt need is a need(s) as expressed by a service user and/orcarer and has gained in increasing importance because of itshuman rights implications and the move towards DirectPayments and personalised budgets.

The overall responsibility for assessing need as described aboverests with the Local Authority

This means the Corporate Authority as well as the AdultServices Directorate of a Local Authority


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Definitions of NeedIn most instances the Duty to Assess and MeetNeed for problematic substance users is a

Target Duty

Target Duties are not concerned with meetingindividual or patient need but addressing therelative needs of the PDU/PDS population as awhole


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Definitions of NeedThe implications of thisare:


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Definitions of Need: TheImplications -

The needs of an individual patient or service user are assessedby 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/PSUpopulation as a whole have traditionally been targeted at thosewith a diagnosed patient need

AND

The role and responsibility for diagnosis rests with Psychiatry


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Definitions of Need: The

ImplicationsIt also means that services identified asneeded can be provided by one service

but funded by another.

However

This DOES NOT alter the statutoryduties to assess individual need.


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Definition of Need: TheImplications

AND

Unless there exists a delegated powersscheme Local Authorities may be in breach of their Duty of Care obligations, this isespecially so where the target duty is

underpinned by a duty to the individual.

AND


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Definition of Need: TheImplications

A duty is owed to the individual when theassessor determines what is needed topreserve or restore normal living

The eligibility criteria has been simplified andstates that Councils should operate just oneeligibility criteria, namely

Should people be helped or not? And if so towhat extent?


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Definitions of Need: TheImplications

Resource allocation matching theassessed needs of a targeted populationas a whole and the numbers of peoplerequiring an individual assessment of need ensures that in urgent cases the

provision of services becomes first andthe assessment second, this isnecessary when meeting emergency orurgent patient need.


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Where does this leave us?

The arrangements made for meetingpopulation need are known as Target

Duties The Adult Treatment Plan andMoC and MoCA bring this to life.

Target Duties must address theresponsibilities for meeting individualand patient need.


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Where does this leave us?BUT

Unless assessed patient need is supported by adelegated powers scheme it is not recognised as anassessment of individual need.

However

In urgent cases of patient need, meeting the socialcare aspects of a medical condition is permitted whilethe individual assessment of need is completed.


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Target Duties allow for the setting up of schemes to address all of the above

BUT

Do not replace the statutory obligationto assess the social care needs of anindividual.


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So.

How do we know who will need anindividual assessment of need?


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Client First: Individual Assessments of Need

Circular LAC(92)12, Housing andCommunity Care

Requires

that assessments focus on thedifficulties an individual and carer isfacing and take account of thefollowing:


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Client First: Individual Assessment of Need

Capacity/incapacity

Preferences and aspirationsThe living situation

Support from family and friends

Other sources of help


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Circular LAC (2002)13 Fair Access toCare Services advocates that the needfor help can be banded into fourcategories:Critical

SubstantialModerateLow


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The banding system is a MUST DOapproach to addressing the problems

an individual has.

However

It is for the Council to decide whatMUST be done


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It would be usual to consider a threat to life,acute health problems, chronic self abuse/neglect and significant harm to self orothers as critical

And

The known susceptibility to the above assubstantial.


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Substantial need can also arise simplybecause the person or their family are

overwhelmed by the volume of problemsbeing faced and can not see a way out of them.

In these circumstance the sum total of thedifficulties are weighed against the ability of the person or their family to problem solve,

with help.


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Moderate Need is usually where the sumtotal of the difficulties being faced are notinsurmountable but the person or their familyare in crisis and would benefit from crisiscounselling and brief interventions.

Low Need is usually where the difficultiesare about securing practical changes orarrangements to address a clearly identifiedproblem area.


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Circular LAC(93)2 states that people withserious and urgent alcohol and drug problemsare likely to need a rapid response asdeterioration may carry social, legal and careimplications

LAC(93)2 makes clear that whereassessments are undertaken by third partiesthat they are aware of other needs for whichthe 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 ortheir family can manage a medical condition in a way

that is normal for them

Both assess the risks of interfering with a personsautonomy when making clinical or other professional

judgements

Both are concerned with increasing and/ormaintaining the independence of the person, theirfamily or carer.


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Are Patient and Client AssessedNeed Compatible?

Expert Patient Programmes are aimed at patientswho can, with supportive help, look after themselvesand can learn to manage their dependency

Complex Case Management Programmes are aimedat those whos personalities make it difficult for themto get help and require case management.

AND


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Are Patient Assessed Need andClient Assessed Need Compatible

Applying Circular LAC(92)12 and LAC (2002)13 toeach 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 thispatient/client group

re a en ssesse ee an


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re a en ssesse ee anClient Assessed NeedCompatible?

However

The provisions made by way of a target dutyare 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 whopresent with other severe physical co-

morbidity

Those with mental co-morbidity, includingpersonality disorder

Pregnant women and nursing mothers, and insome cases their partners


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Other priorities can include:

Patients where there are childprotection issues

Chaotic and long term injectors andthose with cognitive impairment arisingfrom alcohol misuse

Offenders on court orders


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Consumers FirstThe primacy of public procurement and competition law oversocial protection and social welfare law has radically andirreversibly alter the terrain. It is a matter of time until allservices offered to this population will be considered as a thirdparty assessment and not fall within the routine work undertaken by LAs and CCGs. It may take another 10 -20yrs forthe socio-legal ogligations owed to the individuals and theirfamilies to fall within the scope of the OFT and subject to UnfairTerms and Conditions Act.


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What This Means

In short. Nobody Knows. The NHS andSocial Care Act 2012 has ushered in a

requirement for the handling of SuperComplaints. But no mechcanism exits todo this.


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Next Steps

1. Seek permission from the SoS for Health foran EC Article 168 exemption from the

unckecked use of competitive processes.2. Adopt a known approach to assessing

service viability, like Vaible SystemsModelling

3. Ensure that a public service ethos can bedemonstrated.

making sense of complex need

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