A systems approach to care pathways into in-patient alcohol detoxification: Outcomes from a retrospective study

Abstract

This paper describes the effects of the adoption of a systems approach to alcohol service delivery by four previously separate organisations in Manchester, UK that commenced in 1997. The study examined a database of 5542 admissions for in-patient detoxification between 1995 and 2003, which permitted the analysis of changes occurring in the composition of the client group after the adoption of the new model. Findings suggest that working with the systems approach resulted in more effective targeting of people with higher levels of alcohol dependency towards in-patient detoxification. Females and people in stable housing also benefited from increased access in the new system. Increases in planned discharges were observed across all demographic variables, although alcohol-dependent males without stable accommodation found it more difficult to access in-patient detoxification after the new model was introduced. We conclude that in comparison to a loose network of services a co-ordinated and managed service system can improve targeting for in-patient detoxification for most people with severe alcohol dependence but may not do so for all who need access.

Introduction

The NHS and Community Care Act (1990) saw the start of successive health and social care policies throughout the 1990s that encouraged the development of a competitive market designed to improve value for money within service delivery. One by-product of this competition was that services delivered by different organisations often worked in isolation as they competed directly against each other to secure service contracts. This effect is recognised in the new Alcohol Harm Reduction Strategy for England (Strategy Unit, 2004) which highlights inconsistent and incoherent service provision, conflicting accountabilities, poor information on need and responses to it. Consequently, it has resulted in concern over unmet demand and restricted access for more vulnerable service users.

The strategy encourages approaches to treatment founded on the existing evidence base for interventions and best practice approaches where robust evidence does not exist. However, one area that has received limited attention to date within the alcohol literature and is barely alluded to in the National Strategy is the effectiveness of integrating separate services with a whole systems approach to service delivery. This approach is recommended, however, for partnership working in substance misuse by separate bodies within the UKs Department of Health (DOH) (National Treatment Agency, 2005a, NHS Executive, 2000). These approaches have gained considerable attention in other areas of health care (see Pratt et al., 1999, for an overview), including mental health (Goldman, 1998, Cocozza et al., 2000, Amaddeo et al., 2001), older people's services (Audit Commission, 2002, Sheena and Halliday, 2003) depression services (Centre for Change and Innovation, 2005) and primary care (Rowe, 2002). Consequently, the whole system approach is now being widely adopted in many areas of health and social care (Hudson, 2004, Haselgrove and Tibbles, 2005). In the field of addictions, systems approach thinking has been developing for over 20 years across many areas of the globe (Klingemann et al., 1992, Klingemann and Hunt, 1998, Ogborne et al., 1985). In the US the ‘Target Cities Project’ (Institute of Medicine, 1990) has modelled whole systems approaches treatment access by adopting systems of centralized intake and assessment in order to increase accessibility of publicly funded treatment. A similar systems approach has been used for the homeless with serious mental illness; the ACCESS program funded sites in the US to implement systems for multiple service integration (Randolph et al., 1997).

In the UK, systems approaches attempt to maximise the benefits of each service within a service system in a mixed, yet integrated, economy of health and social care. This can enable flexible and targeted access for those with greater need and higher quality user-led access (Rogers et al., 1999). In the case of alcohol services this would be evidenced by the system ensuring targeted access so that people with varying levels of need or complexity of circumstances access the most appropriate services. For example, homeless-dependent drinkers would access supported accommodation that promoted alcohol treatment approaches whereas people living within supportive stable family environments might receive detoxification at home rather than in an in-patient facility. The benefits of taking such an approach to organising and managing alcohol services would include clarity of role and function of system components, reduced duplication of effort, improved use of human and financial resources, improved care pathways and more effective targeting of need. Findings from the US models in substance misuse and mental health show improved project organisation, system integration and access (Morrissey et al., 2002, Guydish et al., 2000, Guydish et al., 2001, Rothbard et al., 2004), but in some cases less improvement in clinical outcomes (Goldman et al., 2002, Sears et al., 2002).

In the mid-1990s, a whole systems approach to alcohol services was adopted in Manchester, UK, at the height of the era of commissioning services through competitive tender. At the time, Manchester had a well-established range of secondary treatment services for alcohol-dependent people. Statutory and non-statutory providers from two NHS Trusts, a Social Service Department and a national charity were providing two in-patient detoxification services, 2-day centres, a community alcohol team and a care management team. These services were loosely connected, but did not function as a service system. There was some degree of suspicion and competition between the services with no clear agreement on roles or care pathways, which resulted in duplication in some areas of service provision and gaps in others. Clients accessed whichever services they could rather than be directed towards those best positioned to meet their needs.

The implementation of a systems approach was encouraged through a tender exercise where four provider agencies had to work together to submit a proposal that embodied the principles of system working; collaboration, common processes and information sharing. Consequently, the Manchester Alcohol Service (MAS) was established in July 1997 by the four organisations to deliver in-patient and home detoxification, community treatment, day care and access into rehabilitation services and other wrap-around services. The aims across the service system were to (i) target people more effectively towards the most appropriate service for their needs, (ii) share intelligence, (iii) undertake joint training initiatives, (iv) make best use of financial and professional resources, and (v) develop care pathways through operating system-wide protocols (Alcohol Concern, 2003). The implementation of the approach occurred with new contracts for each of the services in the system in July 1997 rather than commence through a gradual phased approach.

A key component within the alcohol services in Manchester during the 1990s had been Turning Point's Smithfield Project which delivered day services, supported accommodation and in-patient detoxification (Ryan, 1997). This service provided low threshold, self-referral access and it is from this service that data has been provided for this analysis.

The aim of the current study is to identify changes in the profiles of admissions to the Smithfield Project indicative of increased efficiency in the use of the service within MAS. Indicators of more efficient use of the service are an increased severity of dependence and complexity of need for in-patient admissions post-MAS, along with a maintained or improved treatment completion rate. The ethos of the Smithfield Project was based on providing a low threshold service which would be retained and indicated through the MAS system by clients with high need, low stability and requiring a longer-term period of change continuing to access and make use of the service. Therefore, clients with these profiles should record at least the same rates of treatment completion post-MAS as pre-MAS to demonstrate the service's continuing role of accessible provision within the new service system.