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Executive summary
Section 1. - Background
1. This paper has been produced by an expert group of clinicians and academics in the filed of substance misuse in Scotland and aims to advise ministers on the place of methadone in the treatment of substance misuse in Scotland.
2. Methadone replacement prescribing has evolved rapidly over 20 years in the face of blood-borne virus infection and is now a major element of the treatment of substance misuse in the UK and much of the developed world.
3. Research shows that Methadone is more cost effective in terms of harm reduction than any other medical treatment for opiate dependency. Methadone outcomes improve if delivered as part of a continuum of care with associated psychosocial interventions (wraparound services) available.
4. Harm reduction - including a substantial methadone prescribing programme - is the main plank of Scottish drug treatment strategy since 1994 and Alcohol and Drug Action Teams ( ADATs) and providers have been encouraged to improve access to services by reducing waiting times and increasing capacity.
5. Methadone treatment should be delivered as part of a range of services delivering a continuum of care addressing harm reduction and recovery needs to be based on comprehensive assessment, care planning and review processes in line with national guidance.
6. Treatments specifically aiming to detoxify and rehabilitate drug misusers should also be available. The use of such treatments should be based on a rigorous assessment and review process which includes procedures addressing the increased risks inherent in detoxification. Comprehensive follow up and rehabilitation services should be available post-detoxification.
7. Concerns have been raised around methadone treatment in Scotland - focussing on issues around prescribing philosophy; limited availability of treatment options in some areas; inconsistency in practice and quality of service across Scotland; effectiveness of services - in particular relating to the delivery of acceptable harm reduction and recovery outcomes, crime reduction and the safety of children.
8. Information on current performance of Scottish services is sparse. Services struggle to supply meaningful information on process or outcomes of methadone treatment in Scotland and national data systems are currently unable to give a clear understanding of treatment processes or effectiveness.
9. When surveyed, few ADAT area services are able to supply useful information on treatment process and standards. Many struggle to retrieve information collected clinically. Few services routinely report on outcomes.
Section 2 - Optimising methadone treatment in Scotland
A number of areas requiring attention have been identified by the SACDM methadone project group and the user/carer consultation events. These are:
10. Service commissioners are failing to commission these complex services effectively. All services must be subject to rigorous clinical governance processes in line with local NHS requirements. Commissioning of services along with associated governance and accountability processes requires to be effective at all levels.
11. Most services and local systems are unable to supply valid information regarding activity or effectiveness of treatment programmes. Services are rarely evaluated objectively. Ways of coordinating research and evaluation in order to make best use of the available evidence and identify research gaps should be explored.
12. Many services are unable to demonstrate that they are delivering comprehensive care within national guidance and to acceptable standards and that they are delivering ongoing benefits to all who are in receipt of methadone replacement prescribing. Few services make any attempt to assess outcomes.
13. Services must be needs-led, not service-led. Services are often delivering limited care packages - with simple methadone prescribing in isolation the norm in some areas. Methadone replacement prescribing must be offered as part of a coherent, planned care package. This must include opportunities to access essential "wraparound" services including services addressing psychological health and social aspects of recovery including education or employment.
The project group unanimously agreed that methadone replacement prescribing remains the main treatment for opiate dependency that should be available within the framework of services across all areas in Scotland. This reflects the overwhelming evidence base which supports its effectiveness in the face of little current credible evidence to support other approaches. The group also agreed that methadone replacement prescribing in Scotland can be improved significantly in terms of consistency and quality of practice and process of care delivery. This is supported strongly by user/carer opinion. The following actions reflect changes which will improve our ability to objectively evaluate treatment delivered by Scottish services and will also address specific concerns regarding delivery and effectiveness.
Actions - a comprehensive list of actions for the Scottish Executive, ADATs and services is included. Key actions include:
Improving ADAT/ NHS board accountability and performance management
14. The Scottish Executive ( SE) should consider at a high level their commitment to meaningful joint working regarding commissioning and accountability of substance misuse services - including consideration of the Justice and Health Department performance.
Improving quality of information
15. The SE should set up as a priority a national methadone audit system (incorporating local data collection) which will annually report on methadone prescribing activity, quality and outcomes. A baseline audit should be delivered in 2008/9 OR Pilot sites (chosen from areas of good practice) may be supported in the development and of such systems for national roll out.
16. The SE should prioritise the processes to ensure CHI numbers are recorded on all GP and specialist methadone prescriptions and maximize compliance with the expanded Scottish Drug Misuse Database. Opportunities to optimize the value of these national data (eg data linkage etc) should be considered by a working group charged with this task, reporting to SACDM.
17. The SE should create a governance and accountability process which assures the delivery of basic data. ADATs should report on their methadone services within this framework. Services should be held accountable under local clinical governance processes to demonstrate they have agreed standards of care and regularly audit against them. Nationally this should be part of the Corporate Action Plan process and the NHS accountability review process.
18. The Scottish Executive should set up a strategic process which facilitates Scottish research into treatment effectiveness in general and methadone effectiveness in particular.
Improving effectiveness of services
19. The SE should agree and articulate a philosophy of care for Scottish services as part of the refreshed national strategy.
20. The SE should set up a process to agree national standards regarding replacement prescribing. These standards must address - accessibility; range of services available; waiting times; aspects of care planning and delivery and outcomes. ADATs and services should report on performance.
21. The SE should require NHS Boards to demonstrate effective use of contractual mechanisms ( GP and Pharmacy) and other opportunities (eg Non-medical prescribing) to deliver best value and improved quality.
Integration
22. The SE should require ADATs to report on the degree, nature and effectiveness of integration of services locally
Improving commissioning
23. The SE should ensure the newly reconvened Scottish Advisory Committee on Drug Misuse ( SACDM) and associated processes are effective and relevant as an agreed national advisory structure.
24. SE should consider development of a structure which will deliver clear leadership/direction; greater accountability and performance management nationally for substance misuse services - eg a Scottish " NTA" or similar body
25. SE should review funding streams and associated accountabilities to empower ADATs and facilitate improved effectiveness.
26. ADATs must demonstrate that prescribing services are commissioned in the context of their overall service model and are delivering on agreed Key Performance Indicators ( KPIs).
27. The SE must require ADATs to ensure that services are improving delivery in accordance with the national quality standards for substance misuse services
28. ADATs should be required to use ADAT support resources at least in part to deliver on improvements in quality and performance. This should be incorporated into the local NHS clinical governance agenda and reported through the NHS accountability review process.
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