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Appendix 5 - Summaries of Examples received
Policies, procedures and clinical governance
Tayside substance misuse services supplied their prescribing protocol which covers all prescribing associated with substance misuse. This development was led by the specialist service in partnership with primary care ( GPs, pharmacists and their representatives) and local ADATs. Once completed and signed off by all relevant bodies, standards were developed which allow the clinical governance facilitator to assess performance in terms of consistency and quality of care in all clinical areas. The facilitator post was prioritised by the services to ensure quality of care delivery. The package was introduced to the NHS Tayside clinical governance process - allowing the NHS to oversee prescribing practice in all sectors. The service now reports annually on performance to the NHS Board. The protocol has improved quality of care - with initiation of all prescriptions following comprehensive assessment and care planning and prescribing of methadone only proceeding with associated keyworking (wraparound) services.
Introduction of the protocol (and associated clinical governance processes - training for GPs; improved communication with pharmacists) has resulted in objective improvements in local care - for example, methadone leakage (previously highest in Scotland) has reduced significantly.
Standards and audit
The Lothian n GMS Contract- elements required for National Enhanced Service ( NES) for drug users - NHS Lothian. The contract devised by NHS Lothian contains a simple but comprehensive description of what is required to deliver good practice to patients suffering from drug misuse, in an accountable way.
- It sets out things that need to be already in place - such as an accurate register of patients, good links and liaison with all other relevant agencies and services and systems to record prescribing, interventions and review.
- Funding provided though the contract is expected to deliver care for patients which is in line with guidelines, provide a range of treatment and support, taking account of co-existing physical, emotional, social and legal problems wherever possible, audit and training.
- An annual review, which includes assessment of outcomes is clearly part of the contract, as well as clinical audit of prescribing and prevention of blood borne viruses.
- The skills of the practitioner to assess, advise, test and treat patients are defined, including working in an appropriate multidisciplinary manner.
- GPs receiving funding to treat drug misusers are expected to identify and meet appropriate training requirements.
The contract also contains a 'checklist' of key requirements such as adherence to local and national guidelines, submission of records to the Scottish Drug Misuse database, audit requirements, prevention and care of associated viral infections, outcomes for patients using the Christo Inventory process and recording.
The contract also draws attention to the importance of having systems to record dependent children and sharing information with other professionals.
NHS Lothian has also been monitoring the level and quality of delivery of services under NES arrangements. Through this NHS Lothian is able to identify the number of drug users in treatment, the number of times they see their GP annually about their drug use. For patients receiving methadone the total number and those being supervised are known, together with the average dose they receive. There has been an increase in the numbers of patients being drug tested during treatment. Immunisation or testing for blood borne viruses has increased since the start of the contract. Evaluation of outcomes, using the Christo Inventory assessment tool is now used by 86% of practices, compared to only 27% in April-September 2004.
The audit also identified practices who have difficulty maintaining standards, who should then be visited by the Primary Care Facilitator Team with follow-on audit data to confirm that appropriate changes had taken place.
The Lothian Harm Reduction Team offers a comprehensive programme of care ranging from intensive support on a daily basis through a weekly programme with a Community Psychiatric nurse to low level support. It regularly monitors and evaluates the effectiveness of the various programmes they offer their clients, through an audit group set up for this purpose. Their most recent report, describing the period from April 2005-March 2006 presents findings from evaluations carried out during this period and presents implications for future service delivery. It includes information about outcome measures, including the proportions of clients testing negative for illicit substances, which increase as clients progress through treatment. In a recent evaluation, 46% of respondents had been abstinent from heroin during the previous 30 days. Spending on heroin decreased by 97% in total, while there was a substantial reduction in injecting behaviour with 63% of clients reporting no injecting at all. Clients views about various aspects of their treatment were also sought.
This data will be reviewed on an annual basis and there are plans for another client survey. In particular an evaluation of the comprehensive packages of psychological support services available to clients will be conducted soon. Other evaluations envisaged are investigate the prevalence of co-morbid post traumatic stress symptoms in clients and evaluate the new guidelines for the protection of children of parents with substance misuse problems. Clients motivation to change is currently being assessed. A user involvement group is currently being established.
Process of Care delivery
NHS Tayside reports availability of detailed information on developing care pathways which have been developed using an evidence-based process of prioritisation - the PBMA process (Programme Budget Marginal Analysis). This process involves all service providers and commissioners agreeing needs assessment; programme budget currently delivering services; services delivered and their effectiveness before entering a process of "investment or disinvestments" where resources may be removed from ineffective services (or services whose value is no longer demonstrable) and used to develop new services.
NHS Grampian has introduced a single integrated service in 2000. This service involved the NHS, social services and voluntary sector. Under this agreement Single Shared Assessment, Review and Careplanning Tools have been developed. A community rehabilitation service integrated with substitute prescribing services has been piloted. A new Integrated Careplanning and Stabilisation service is being developed that will bring together Specialist GPs, Nursing, Social Work and Voluntary Sector to work with clients to undertake multi-disciplinary assessment, stabilise drug use through enhanced prescribing and careplanning, with clients then moving onto community services. Aberdeen City has a high proportion of GP practices participating in Shared Care and the new service will further enhance that provision by redesigning Specialist GP inputs to the most complex and time consuming part of assessing and stabilising drug users.
Information systems
Many services advised they collected data but had insufficient resources/expertise to retrieve this information.
Outcome measurement
Lothian DTTO supplied the report "Delivering Effective Drug Treatment in the Criminal Justice System". This report showed how a simple system of data collection in the clinical setting can supply valuable data on effectiveness - with the DTTO able to report on characteristics of their client group at assessment as well as progress by regular and frequent drug testing and injection sites through physical examination.**
Glasgow addiction services supplied the research report "Impact of methadone on crime in Glasgow". This reported research carried out by SCIEH and described the law-breaking activity of drug misuers in treatment on methadone - supporting the view that crime often reduces initially. The report did note that offending increased after this initial improvement.
Tayside substance misuse services has assessed all patients on methadone in all settings as part of its service redesign. A database was designed and NHS Tayside made resources available to support data entry. This allows initial assessment of the treatment population using the MAP as well as a number of screening tools for co-morbidities such as anxiety, PTSD, chronic pain etc. This exercise is ongoing - but some 21% of those prescribed methadone have been assessed as "stable" against a range of criteria which includes clean urinalysis. The service is now collecting 3 monthly outcome data and is exploring ways of having a robust data management system which will allow reporting of these outcomes regularly.
Tayside also has access to the MEMO database - a clinical database containing all prescriptions issued by GPs in Tayside from 1992 - Chi identified. The MEMO system allows these data to be linked with other Chi data (eg drug deaths; admissions etc) and then anonymised. This raises the potential to look at l ong term outcomes in very large datasets (4000 patients prescribed methadone over ten years) and consider epidemiological analyses of risks etc.
Lothian low threshold methadone programme supplied the research paper "Evaluation of a pilot low-threshold methadone programme" produced by service staff and NHS Board public health. This paper showed significant short term impact on risk behaviour and health indices up to 8 weeks into treatment.
Specific service examples
Methadone Maintenance Treatment in Scottish Prisons
In July 2003, 587 prisoners were in receipt of a substitute prescribing regime, by June 2005 this figure had increased to 886 prisoners. To evaluate its policy on methadone maintenance the SPS commissioned research into the effectiveness of the change in MMT policy. The principal aim of this study was to examine the role and impact of methadone maintenance treatment for the individual prisoner receiving it and collectively for the prison.
The study was located in five establishments. These establishments were chosen as they held different prisoner subgroups (long-term, short-term and female prisoners). Prisoners were recruited from each of the five prisons. The sample was stratified into 30 long-term male prisoners, 30 short-term male offenders and 30 female offenders. Each group was divided into two groups of 15 from two different establishments. Between three and five prison staff, from different occupational groups, were recruited from each establishment.
Semi-structured qualitative interviews were conducted with 90 prisoners and 17 staff between March and December 2004. Topics discussed at interview with prisoners and staff were 'why intravenous drug users decide to start MMT in prison and why some choose not to; prisoners' perceptions of the process of methadone prescribing in the prison setting; the effect that MMT has on the quality of an individual's life in prison; the impact of methadone on behaviour including areas such as risk behaviour avoidance, social interactions, relationships and networks; perceptions as to whether MMT alters prison dynamics and levels of violence or intimidation between prisoners; whether MMT motivates drug users to seek help to address social and psychological problems attendant with incarceration. Attitudes of staff towards MMT were also sought.
The research identified a number of disincentives MMT and some problematic issues but its overall findings are that many benefits to be gained from MMT in the SPS, and the evidence is overwhelmingly in support of continued investment. However, if potential benefits are to be maximised an improvement is required in the management of this treatment.
Community Rehabilitation and Wrap-around Services
NEW HORIZON, Glasgow
ETHOS: The approach taken by New Horizon is epitomised in its mission statement 'To Empower'. This statement applies to service users and staff alike and emphasises the vision of realising the full potential of workers and service users.
SERVICES: These include- Key Work, Group Work, Relapse Prevention, Cognitive Behaviour Therapy, Auricular Acupuncture, Yoga, Fitness Suite, Community Café, Music and Drama Workshops, Personal and Social Development, Family Support, Volunteer Opportunities, Service User Involvement, Further Education Learning Centre and Employment Guidance.
STAGES:
1. PRE-ENTRY: Designed for those who are still drinking or using drugs this stage focuses on the motivation and change required to progress to the main programme.
2. MAIN PROGRAMME: For those who are on Methadone only, verified by testing, or alcohol/drug free. 5 modules aim to assist individuals with issues relating to their dependence while at the same time introducing a focus on future aspirations towards training, education and employability. It is during this stage that some service users express a wish to detox from methadone. This would be arranged with the agreement of the service user, case manager, prescriber and the New Horizon key worker.
3. POST PROGRAMME: Provides ongoing support with issues relating to dependency and a more in-depth focus on employability. Collaboration between therapeutic and employability staff enables service users to access the support required to work towards their aspirations in relation to learning and employment. This stage involves linking in with other partners and agencies to ensure that the all the elements of the employment pathway meet the needs and aspirations of the service user. It is at this stage of the programme many service users aspire to be alcohol and drug free which would entail being free from methadone and all illicit drugs.
AFTERCARE: On completion of the programme ongoing support is provided with the aim of sustaining progress and maintaining momentum towards personal goals.
MOVEMENT BETWEEN PROGRAMMES: Movement between stages is determined through the assessment and review processes and aims to match the service user with the appropriate stage in the programme. Drug and alcohol testing is part of the assessment process.
OUTCOMES: In 2006-7, 125 clients engaged with the service. 78 people participated in stage 1, 97 in stage 2 and 71 in stage 3. 15 people detoxed from methadone, 6 from alcohol. 97 accessed learning, 23 accessed college, 9 entered a training programme. 11 took up voluntary work, 7 part-time work and 8 full-time work.
Community Pharmacy Services for Drug Misusers
Three national surveys about community pharmacy services have been conducted in 1995, 2000 and 2005. A postal questionnaire was sent to all community pharmacists in Scotland (n=1166) to be completed by the main pharmacists. The same questionnaire was used in 1995, 2000 and 2005 with only minor changes so that results could be compared. The questionnaire covered:
- Attitudes to drug users and providing professional service
- Involvement in professional services (needle exchange, dispensing - including methadone supervision)
- Training experience and needs
There has been a significant rise in pharmacists' involvement in dispensing for drug misuse, with 79% dispensing methadone in 2005 compared to 69% in 2000 to 54% in 1995. 72% of pharmacists supervised methadone consumption of patients. The mean number of methadone patients per pharmacy is 20 increased from 13 in 2000 and 7 in 1995. In total, over 17,000 people are estimated to be dispensed methadone from all pharmacies in Scotland. Of these, 57% take their methadone under pharmacy supervision. Although two thirds of pharmacists have had specialist training there is still a need for more. Methadone dispensing workload is now considerable and although pharmacists seem largely positive about providing this service the volume may become too great. This needs to be planned for now. The increase in clients using needle exchanges but the relatively low level of pharmacy service provision need review.
A further CSO funded study has explored a pilot project in which 11 community pharmacists supervising the self administration of methadone have been trained in motivational interviewing techniques. The study showed positive changes in pharmacists' attitudes and belief in self-efficacy and patient reported changes in pharmacist behaviour indicate that the training could be effective. Funding for a large scale Scottish wide RCT to further evaluate this training has been applied for.
Case studies - contribution of methadone treatment to recovery
Case studies can add an important personal aspect to a debate which is dominated by cold objectivity. All clinicians can (and do) quote examples of how their own approach was effective and how others' was not. However, these few are included - not as support for or rejection of the use of methadone - but to illustrate what the evidence base actually shows - a range of approaches is required for most substance misusers and a coherent process of care involving a partnership between skilled professionals and the misuser can achieve impressive results.
The range of different ways in which methadone can contribute to recovery to opiate addiction was illustrated by nine case studies involving clients of Glasgow Addiction Services. In five of these cases, clients are now drug free, including in three family situations.
In three of the cases, residential treatment was also part of the care process. The treatment journeys were :
- Methadone treatment with regular contact, support, setting of goals and identification of barriers led to detoxification in residential rehabilitation, a drug -free life and plans for employment
- Methadone detoxification within a residential setting followed by relapse on release, which, after a further period of high risk drug use, led to successful residential rehabilitation, ability to live in supported accommodation, rebuild family relationships and pursue an electrical apprenticeship.
- Relapse after residential rehabilitation led to community rehabilitation and successfully detoxing from diazepam. Although still receiving methadone, client is accessing college, managing stress, has a greater awareness of trigger situations and improved coping skills.
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