How could commissioners re-commission an adult ADHD service effectively?

M Aamer Sarfraz 
Carlos Almonte 
Hugh Logan – Ellis 
Hamid Rahmanian 
Imran Qazi 
Christiana Lewis 
Elizabeth Raybould Centre, Dartford

Introduction

Attention Deficit and Hyperactivity Disorder (ADHD) is a neuropsychiatric syndrome found in children with a triad of symptoms related to hyperactivity, impulsivity and inattention. Research since the 1990s has confirmed that a significant number of children with ADHD continue to have symptoms into their adult lives. In adulthood, the hyperactivity decreases, but inattention, disorganisation, and impulsivity might remain, resulting in difficulty in functioning at home and at work (1). Such patients are more prone to other psychiatric symptoms and disorders including substance abuse and associated risky behaviours. Treatment of ADHD includes psycho-education and pharmacotherapy for ADHD and comorbid disorders, coaching, cognitive behaviour therapy and family therapy (2).

The prevalence of ADHD in adults is 2-5%, and 10-20% in those with common mental health disorders.  These rates are higher among those attending forensic, addiction and personality disorder units, which highlights the importance of screening for adult ADHD in such high-risk populations (3, 2).

Our Trust is not commissioned for the treatment of adult ADHD.  Therefore, such cases are referred to the specialist centre at the Maudsley for assessment & treatment.  This happens despite local consultants being able to diagnose & treat adult ADHD. Following assessment at the Maudsley, they are sent back to the General Practitioner (GP) to implement the treatment plan.  In a number of cases, we (secondary psychiatric service) are requested to manage the co-morbid disorders.  This leads to confusion among clinicians regarding their treatment roles and causes additional stress to the patients and their carers.  A single referral to the specialist centre costs the Clinical Commissioning Groups (CCGs) £1250 with a limited scope for re-referral if the treatment plan does not work.  The waiting time for the approval of funding from the CCGs and subsequent specialist assessment can take up to 12 months.

Adult ADHD patients in whom the diagnosis has not been made and/or where ineffective treatments are in place for alternative diagnoses, add to higher rates of presentations to A&E departments and mental health services along with health, legal and financial risks & implications.  Transition from child to adult psychiatric services also remains a major concern for having no local service level agreements between various care providers because ADHD treatment is not commissioned for the adult population.

NICE clinical guidelines (4) are a great resource for healthcare professionals to develop, with relevant agencies, effective services for the diagnosis and management of adult ADHD. These guidelines make a case for commissioning services for the diagnosis and management of ADHD, specify service requirements, and help determine local service needs while ensuring quality.  They also cover the transition of ADHD cases receiving treatment from child mental/health services to the adult mental health services.  Department of Health – DoH (5) made similar recommendations earlier after highlighting the multidimensional social, health and legal needs of adult ADHD sufferers and their carers.

Various government initiatives over time, including National Service Framework (6) New Ways of Working (7) and New Horizons (8) for mental health services, have recommended faster, equal & easy/local access and ways to combat discrimination against individuals/groups of patients to prevent future crises of care.  More recently, chief executive of the National Health Service (NHS), Simon Stevens, has talked (9) about commissioners finding smart ways of getting more value for money while appreciating the pull for treating patients close to home though more local & community-orientated services.  He also argued that medical training and staffing should not drive the wholesale reorganization of district general hospitals across England.

There is no doubt that NHS is facing a financial challenge and needs to come up with considerable improvements in performance & outcomes if it is to continue providing high-quality services without additional funds.  Therefore, there is a great drive from DoH, cascaded down to commissioners/CCGs to improve productivity in mental health services while offering support for coping with the future challenge of building a preventive and empowered mental health systems (10).

Case example:

An interest group of consultants experienced in treating adult ADHD met on three occasions and produced:

1) Current system/journey of ADHD patients within the Trust – attached as appendix1

2) Summery of skills/resources available in the Trust to set up an adult ADHD service

This group was divided into two subgroups. The first subgroup surveyed adult ADHD services in and outside U.K. and produced a protocol for use within the Trust – attached as appendix2.  The second subgroup met with finance and development directors.  They also collated data acquired from CCGs to know how many cases of ADHD were referred & treated outside the Trust and its cost.  I was a member of both subgroups and kept the main group informed.

Table1: Number of adult ADHD referrals, assessments and treatments over 3 years across our Trust

                                             Our Trust

 

 2010/11

 2011/12

 2012/13

No of adult referrals

191

437

526

No of adult assessments

156

213

356

No of Adult treatments

418

512

685

 

Table2: Number of follow-up appointments for those referred over the 3 year

Period

Number of sessions

01/06/10 – 31/03/11

266

01/04/11 – 31/03/12

320

01/04/12 – 31/03/13

400

 

It is clear from Table1 that adult ADHD referrals, assessments and treatments have been increasing year on year.  It is also an unmet need & a risk that less than half of those referred could not be assessed due to possible problems with funding, diagnoses or being ‘lost’ due to delays in organising funding or assessment.

The cost of 356 specialist assessments (2012/13) alone is £445000.  It is estimated that adults with ADHD have annual expenditures that are approximately $3,000 greater than adults without ADHD (11).  If we include charges for follow up and those of screening & ongoing treatment of additional diagnoses at the secondary care service, the overall cost would easily cross one million pound per annum.

In order to develop a new adult ADHD service, resource implications are of paramount consideration.  There are five community psychiatry hubs in our Trust.  Most of the ‘cold’ referrals from GPs and others sources are received there.  The acute referrals where urgent inpatient or home treatment is required are received at the Crisis & Home Treatment Team.  It would make sense that the new ADHD service is a part of the community service-line because bulk of the work sits there along with the resources.  The acute referrals to inpatient units can be picked up through interface meetings, which take place daily. 

Workforce

Most patients with ADHD & comorbid disorders are already within the adult psychiatric services.  Considering the prevalence of adult ADHD (3-4 %) and quicker discharges back to the GP in most cases after first assessment, implications for a large increase in recruitment of staff are minimal.  Each hub can evaluate their existing skill mix and may decide to recruit an experienced lead nurse (approx. £40,000 per annum) and perhaps a staff grade doctor (£60,000 per annum) for this service.

 Training & education requirements

Good quality one-day courses for mental health professionals who either want to work in ADHD service or refresh their relevant skills are available at £250 per person.  Since this is a Trust-wide initiative involving many professional, organisers of a course can be invited to run it at the Trust site at discounted rates.  From there on, medical/nurse education and learning & development departments can ensure that ADHD is a subject for ongoing continuous professional development programme for the relevant staff and forms a part of their annual appraisal.

Funding

Lead nurse practitioners (x 5)   = £200,000                       

Staff Doctors (x 5) = £300,000

CBT & Social skills training = £ 20000

One-off course (30 x £250) = £7500

Grand total = £527,500

Annual CPD for all ADHD professionals in the Trust = £ 10000

Keeping in view all the above, consultations with Trust directors and communications with the CCGs, a robust case for a local adult ADHD service can be made.  Objectives of this new service may include: early identification, accurate assessment involving relevant organizations/significant others, smooth transition from child into adult services, improve joint working, review systems & outcome measures and improved skills for professionals through training & supervision.

Commissioning Challenges

As commissioners, various challenges need to be tackled in the process of deciding to re-commission an existing service because commissioning for quality and care is “a multifaceted concept…not amenable to a single performance measure or simple metric” (12).  They need to take into account views of different stakeholders including patients, clinicians, practitioners, managers and leaders.  They also need to consider that any new proposal is consistent with current professional knowledge and ensures: easier, timely & reliable access; cost effective use of resources in primary/secondary care; good interface & joint working and ability to monitor & control quality though key performance indicators.

Commissioners would keep in view the recommendations made in the white paper (13) that patient should be central to the process (vis-à-vis choice, control and compassion) and clinical outcomes are delivered through empowered health professionals.  In line with that, before deciding to move from current to the future model of care, the first challenge for commissioners is to look at ‘proof of value’ (14) in the proposal.  One of the ways to evaluate its outcomes is by examining three dimensions (patient, professional, management):

* Clinical outcomes: measure of symptoms & functionality, compliance & optimization of medicines, improvement in detection & treatment

* Financial outcomes: reduction in outside referrals, DNA rates, mental health contacts and overall costs 

* Quality outcomes: measure of Quality of Life, increase patient choice, improve partnership working and improve patient experience & engagement

A more comprehensive way (15) to evaluate this proposal is through “Seven Dimensions of Performance” (effectiveness, efficiency, safety, timeliness, equity, coordination, and people-centeredness).  The proposal seems to be effective as it has clear clinical outcomes and patient journey (Appendix2) is less complicated with obvious potential to improve their quality of life.  This is also more cost-efficient in terms of finance & time-consumption.   Regarding safety, a local service could be more reliable and prevent referrals lost during transition from child to adult services.  A local service also has the potential to reduce waiting times & inequalities, provide greater access and be user-friendly.  Some variables in these dimensions cannot be considered (e.g., patient experience, portability, cultural sensitivity, etc.) at this stage or could only be evaluated when the system is in place.

The next step for the commissioners is to decide what approach they want to take regarding tendering.  If they are convinced about the merits of the proposal, they could ask our Trust to put up a formal business case while pursuing the Kotter (16) approach.  Alternatively, they could take the tendering route perhaps by pursuing the ‘qualified provider’ approach.  However, the latter may not be suitable because it would be similar to the current commissioning model with risks including inefficient access, impaired joint working and higher costs. 

If our Trust is commissioned, the next possible steps for the commissioners, following Kotter approach, would be: create & communicate your vision to the Trust, establish a sense of urgency, empower the Trust & set-up relevant achievable short-term steps, and agree upon ways to consolidate/institutionalise the new service.

In case of re-commissioning, the existing providers could lose £0.5-1.0 million per annum.  The commissioners would need to meet them before & after making the decision and communicate how they have reached the decision to re-commission.  Since the current providers may feel aggrieved and highlight their specialist credentials, the commissioners could decide to partially compensate them by offering to remain a tertiary referral service, just like others specialists services at the Maudsley, for giving second opinion to locally identified complex cases and also offer training courses to the local staff.  

Conclusions

Adult ADHD is a neuropsychiatric disorder with national gaps in treatment/management services.  Due to its associated risks, care burden and rising costs, it has become a commissioning challenge for stakeholders.  A current commission model for an adult ADHD service was examined along with its risks, and a strong case for re-commissioning is made using a case example backed up by NICE & DoH guidelines and various government policies and initiatives.

** We are grateful to Drs. Karen White, Rehab Khalifa and Vijay Delaffon for their advice

Appendix 1

Current Practice

Variability and inconsistency across our Trust

The current model is not cost effective for commissioners and is not in concordance the local commissioning framework

Appendix 2

Clinical needs & resources  associated with patients’ care pathway in adult ADHD services

Stages in the pathway:

  • Referral / Screening phase
  • Diagnostic assessment
  • Titration / Stabilisation
  • Psychotherapeutic interventions
  • Follow up

Referral/ Screening Phase:

Patient referred by GP/ Consultant Psychiatrist

  • Collecting further information / notes from GP/ Consultant Psychiatrist, arranging appointment/ screening tools sent out to patients to complete
  • Referrals discussed at fortnightly referrals meeting
  • Attended by Multidisciplinary team including Consultant Psychiatrist, Psychologist, ADHD Nurse practitioner/s (2-3 hrs)

– review referral and screening tools completed  and allocate to one of the clinics (15 mins / patient)

– discuss new patients’ diagnostic assessment and agree care plan (30 mins/patient)

– discuss follow up patients (15 mins/ patient)

Diagnostic assessment:

  • 3 hrs with a Consultant Psychiatrist at one of three clinics over 3 appointments
  • 1 and ½ hr with ADHD Nurse practitioner – community setting (1hr) clinic with Consultant Psychiatrist (½ hr)

Psychotherapeutic interventions:

  • Group CBT delivered by ADHD Nurse practitioners over 12 sessions at one of three clinics (45 mins/ patient)

Titration/ Stabilisation Phase:

  • 3 hrs with a Consultant Psychiatrist at one of three clinics over 4 – 6 appointments

Follow up Phase:

  • 30 mins with a Consultant Psychiatrist/ ADHD Nurse Practitioner at 6 monthly intervals at one of three clinics

Service level resource needs:

  • Training for Consultant Psychiatrists in diagnostic assessments and treatment
  • Training for ADHD Nurse Practitioners in delivering CBT/ Social skills training
  • Supervision for individual clinicians
  • Pharmacological interventions
  • Education of GPs and establishing Shared Care protocols
  • Interface meetings with other services – CAMHS/ General Adult/ Forensic/Prison services
  • Service evaluation and Clinical Governance activities

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