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Reducing harm and promoting recovery: a report on methadone treatment for substance misuse in Scotland: SACDM Methadone Project Group

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Section 2: Optimising methadone treatment in Scotland

This section will describe the areas which require attention and the actions required in order to improve the delivery of methadone treatment services in Scotland.

2.1 Gaps in Scottish service provision

There are a number of key delivery areas where it is clear that action is required to improve Scottish treatment services.

2.1.1 Improving accountability and performance management

There is a need to put in place a meaningful governance and accountability structure which is of relevance and which local systems are required to answer to through robust performance management systems

Accountability arrangements for ADATs are currently being reviewed in light of concern that ADAT performance must improve. An ADAT review in 1998 led to new accountability arrangements incorporating increased support for ADATs to upgrade support officers and improve effectiveness and that support currently runs at £2.2m per annum. More recently the SE put in place "performance contracts" to require ADATs to demonstrate effectiveness with regard to new funding. National standards and actions around waiting times and drug deaths have created further obligations with no obvious impact on performance.

Methadone prescribing is one area where effectiveness of ADATs - and the quality of their partnership arrangements - is reflected in local quality and performance. Medical services are managed by NHS partners and, unless locally coordinated in an accountable way, it is likely that there will be diversity of practice and delivery - even between the various service elements in a local ADAT area.

1.1 There is an urgent need for the Scottish Executive Health and Justice Departments to work together to put in place arrangements that cement meaningful accountability arrangements with key performance indicators relating to 1. new funding availability for services and 2. ADAT support. Ultimately this process should evolve to govern all spending of ring-fenced resources on substance misuse and should inform the accountability process for non-ring-fenced NHS and Local Authority resources. Key Performance Indicators ( KPIs) should be developed and should include the ability to demonstrate coherent strategic direction; quality commissioning which requires reporting of outcomes and improvement plans for failing services.

1.2 There is a need for the SE to consider improved governance arrangements - looking elsewhere in the UK - eg the development of a new national body (similar to the National Treatment Agency ( NTA) for England and Wales) incorporating elements of existing national bodies/processes (eg Quality standards; Scottish Association of Alcohol and Drug Action Teams - SAADAT) and funded through existing ADAT support resources. The NTA has seen improved performance from services in England but would require an innovative approach from the SE to address its current performance around this key cross-cutting agenda.

2.1.2 Improving quality of information - demonstrating effectiveness

Most services are unable to supply robust information regarding activity or effectiveness. Services are rarely evaluated objectively. There is a need to improve the coordination and impact of Scottish research in substance misuse treatment.

2.1 There is a lack of good quality monitoring/audit data on who is prescribed methadone, by whom, with what dosage, duration, and effectiveness in terms of improvements in risk-taking, motivation, social circumstance and level of dependency.

2.2 More broadly there is a lack of independent evaluation of the majority of our drug treatment services with which to assess the relative impact of individual services or combinations of services.

2.3 There is a need to improve the quality and coordination of Scottish research in this area. A meaningful research strategy which considers treatment options and their delivery needs to be put in place, building on and coordinating the activity of Scottish researchers in the field. The (primarily) policy-based research which is currently commissioned does not appear to be part of a coherent programme. Coordination with other UK or international researchers and strategies should be improved.

2.1.3 Improving effectiveness of services

Services require 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.

3.1 Philosophy of treatment services and the outcomes expected by commissioners need to be clearly described locally and nationally in the relevant documentation (eg strategies, prescribing policies). While long-term methadone is required in many cases, this must not simply be a default position and if delivered must be associated with objective progress (both harm reduction and recovery outcomes) and based on an agreed and recorded care plan.

3.2 Objective quality of harm reduction services must be improved. Quality and effectiveness of services is inconsistent across Scotland. Outcomes are often hard to determine. Objective outcomes must be clearly recorded against an agreed care plan and should be the basis of a reporting system.

3.3 There is often a lack of a clear local strategy to manage the capacity of services. This would involve continuous review of resource management to meet need and would include the requirement that access to methadone is linked with clear objective review of progress against agreed harm reduction and recovery goals and service performance indicators. If functioning optimally - but struggling to meet need - commissioners require to consider investment in services.

3.4 Opportunities to embed quality agendas into prescribing/ dispensing through contractual mechanisms and opportunities (eg enhanced service contracts for GPs; Locally negotiated community pharmacy contract; non-medical prescribing) have not been capitalised on. Participation in such contractual arrangements should include a requirement to adhere to national standards alongside robust local clinical governance.

3.5 There is a lack of consistency and quality regarding information sharing. Communication between agencies is inconsistent. This inevitably impacts on care planning and case management - and ultimately effectiveness.

3.6 There is a lack of clarity regarding expectations of treatment. This includes the service's expectations of those receiving treatment and the user's expectations of the service. We need to be much clearer with what aim treatment is being provided and what are the short term, intermediate and long term goals. This must be discussed and the treatment agreement recorded. An ongoing process of care planning is required to ensure services continue to assess need and respond as individuals' needs change.

3.7 There is a lack of consistency in terms of users' and families' involvement in the process. This impacts on choice of treatment options and may limit progress.

3.8 There is a lack of choice for the service user in pharmacological treatments. It must be clear what is locally available and why such prioritisation decisions have been made.

3.9 There is a lack of adequately trained staff to deliver comprehensive care packages. There is a need to ensure staff are appropriately trained in delivery of treatment programmes.

3.10 Child protection must be a central element of service delivery. Systems must be in place to ensure this is addressed.

2.1.4 Integration - methadone replacement prescribing must fit into a coherent, planned care package

Methadone replacement prescribing must not be delivered in isolation but 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.

4.1 There is poor integration between our medical (replacement prescribing) services, other - abstinence orientated - medical services (eg detoxification and naltrexone) and those additional - non medical - service elements (either in the community or within residential settings) eg counselling/wraparound services; care planning and integration of care around the user; availability of psychosocial therapies/moving on services/etc.

4.2 There is a lack of availability of structured "wraparound" psychosocial care services alongside prescriptions. This should include more effective working between drug services and training, education and employment services.

4.3 There is a lack of care planning with associated goal setting and review of individual progress in prescribing services.

4.4 There is little evidence of effective engagement with self-help approaches.

4.5 There is a need to set basic standards regarding information-sharing in clinical services

2.1.5 Improving commissioning - national and local strategic issues must be addressed

Commissioning of services along with associated governance and accountability processes requires to be effective nationally and locally.

5.1 There is a lack of coherent leadership at national level. SACDM's role and credibility have suffered in recent years. National strategy requires to be refreshed in a manner which increases credibility of governmental response. The decision to share policy responsibility by Scottish Executive Health and Justice departments has helped neither service effectiveness nor integration. Services need meaningful feedback from Ministers/ SE in order to improve their functioning alongside encouragement to be innovative and effective in service delivery - eg service integration or MCNs.

5.2 Quality of commissioning is inconsistent. National funding streams do not facilitate ADAT effectiveness. Local ADAT partnerships must demonstrate clear processes of needs assessment, targeted commissioning and evaluation and effective governance of resources. Funding for core prescribing services should reflect local need and delivery of acceptable performance against locally agreed outcomes in line with national targets. This should be subject to meaningful accountability processes. High demand can lead to reduced quality of care. Areas of high demand should have active plans in place to address waiting times as well as effectiveness of services in terms of outcomes and progress to recovery.

5.3 There is a lack of coordination and funding for audit/ governance activity. We need a national organisation using agreed tools for quality/process and outcome measuring. This must be reflected in local commitments to NHS clinical governance processes incorporating all relevant NHS elements - primary care; specialist services; commissioning.

2.2 Recommendations

There are clear areas for action at all levels - Scottish Executive (Health Dept and Justice Dept), commissioners of services, service providers - which require to be addressed if the delivery of methadone services in Scotland is to continue to be accessible while delivering improved outcomes.

This section describes headline and priority actions agreed by the SACDM methadone project group. Potential areas for pilots to be commissioned are identified - [Pilots]

2.2.1 Improving accountability and performance management

There is a need to put in place a meaningful governance and accountability structure which is of relevance and which local systems are required to answer to through robust performance management systems

1.1 The SE should consider at a high level their commitment to meaningful joint working regarding commissioning and accountability of substance misuse services. This must include consideration of the Scottish Executive's commitment to addressing substance misuse and the place of SACDM. If there is such commitment -

1.2 The SE should ensure reconvened SACDM and associated processes are effective and relevant and should ensure key processes - eg refreshing national strategy or specific strategic actions - have taken stock of expert opinions through an agreed and credible national advisory structure

1.3 The SE must address inconsistencies regarding Justice/Health Dept. approaches to accountability and governance and ensure priorities are aligned.

1.4 The SE should convene an expert group which may include ADAT Chairs/Lead officers, professionals from statutory (health, criminal justice and social work) and voluntary sectors along with key Substance Misuse Division and Health Department staff to bring forward options for the development and delivery of a new accountability structure to address the long term failings, from SE to service level, of current arrangements. This body may mirror elements of the NTA. Its remit should be to create a firm accountability and governance structure utilising existing resources when possible as well as creating a national network requiring local partners to effectively use resources to improve governance and accountability; development of quality standards and KPIs around these services; development of and support for an evaluation, audit and research strategy.

1.5 The SE should consider development of a process which better facilitates high quality Scottish research into treatment effectiveness (including methadone).

2.2.2 Improving quality of information - demonstrating effectiveness

Most services are unable to supply robust information regarding activity or effectiveness. Services are rarely evaluated objectively. There is a need to improve the coordination and impact of Scottish research in substance misuse treatment.

2.1 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 2007/8 OR Pilot sites may be supported in the development of robust quality systems [Pilots]

2.2 The SE should support local ADATs in the development of systems to capture key data, incorporating: development of an agreed national minimum dataset to monitor activity and outcomes; commissioning the development/modification of IT-based systems of data management which deliver key information to the services, ADATs and the SE. [Pilots]

2.3 The SE should prioritise the processes to ensure CHI numbers are captured on all GP and specialist methadone prescriptions and maximize compliance with the expanded Scottish Drug Misuse Database.

2.4 ADATs should identify how they will meet their responsibilities regarding implementation of the National Quality Standards in particular regarding arrangements for monitoring and evaluating services. [Pilots]

2.5 NHS services should be held accountable under local clinical governance processes to demonstrate they have agreed standards of care [2.4] and regularly audit against them. Nationally this should be part of the Corporate Action Plan ( CAP) process and the NHS accountability review process

2.2.3 Improving effectiveness of services

Services require 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.

3.1 The SE should agree and clearly articulate the philosophy of care for Scottish services as part of the refreshed national strategy - this must address the need to maintain harm reduction as a key requirement but emphasise the need to promote recovery.

3.2 Delivery partners should ensure availability of clear local policies/procedures regarding prescribing - these should address issues of philosophy of care.

3.3 The SE should agree national standards regarding accessibility; range of services; waiting times; key aspects of care planning and delivery and desirable outcomes.

3.4 The accountability process must include a requirement that services deliver against agreed national standards OR can demonstrate credible mechanisms to address deficits identified in baseline data.

3.5 All ADATs should clarify how they aim to utilise the developing contractual opportunities (eg GMS National Enhanced Services; Community Pharmacy; Non-medical prescribing) to improve quality. Plans submitted should form the basis of ongoing ADAT accountability process. SE should consider opportunities to deliver and evaluate pilot projects regarding these key areas in areas of innovation. [Pilots]

3.6 Needs assessment - SE should require all areas to undertake local needs assessment regarding information sharing process - availability of protocols and standards; performance; improvement plans. This needs assessment must address such areas as child protection and service interfaces ( SPS; in-patient admissions)

3.7 Information and contracts -SE should require ADATs to report on the use of goal setting/contracts. ADATs should agree with service providers information requirements regarding what services are available and the processes associated with their delivery. This must include standards regarding timeframes and communication; process elements including review and care planning; accessibility of advocacy services and complaints procedures. ADATs should agree with service providers a mechanism which ensures there is agreement regarding treatment goals and procedures which is subject to regular review.

3.8 Range of services - Using existing evidence and national guidance the SE should develop national standards regarding what treatments should be available locally in a comprehensive care system. Local systems should make clear statements regarding availability of medical treatments - what is available and in what circumstances; associated processes and standards; what is not available and why. This should incorporate user information systems.

3.9 Staff training - Local systems must have clear staff development plans which are aligned with their strategic and operational objectives. National organizations (eg STRADA) should work with ADATs to deliver tailored training packages to meet changing needs.

3.10 Child protection - Local systems must have in place robust plans to ensure child protection performance is audited and meeting national standards.

2.2.4 Integration - methadone replacement prescribing must fit into a coherent, planned care package

Methadone replacement prescribing must not be delivered in isolation but 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 of employment.

4.1 SE should require ADATs to report on degree, nature and effectiveness of integration of services locally (incorporating work of SACDM integration sub-group)

4.2 SE should also address local delivery of "A Joint Future" through existing accountability processes

4.3 SE should require ADATs to have clearly articulated plan to address self-help element of recovery process and should report on progress as part of governance process

4.4 Services should be required to demonstrate that they have systems which support information-sharing between services/professional groups

2.2.5 Improving commissioning - national and local strategic issues must be addressed

Commissioning of services along with associated governance and accountability processes requires to be effective at all levels - SE/ ADAT and NHS Boards/Services.

5.1 SE should explore options for delivery of improved clinical governance networks to enhance consistency of services - eg MCNs [Pilots]

5.2 SE should review funding streams and associated accountabilities to empower ADATs and facilitate improved effectiveness.

5.3 SE should exploit current structures - ADATs/ SAADAT - to identify baseline in terms of nature and quality of local commissioning processes. SE should set basic standards regarding quality of commissioning and assess all ADATs against these standards. ADATs/partners should ensure membership is fit for purpose - including links with local medical structures - eg Area Medical Committees.

5.4 ADATs must demonstrate that prescribing services are commissioned in the context of their overall service model and are delivering on agreed KPIs

5.5 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 NHS clinical governance agenda and NHS accountability review process.

5.6 Services must supply ADATs with coherent and valid plans for managing demand. If they cannot the ADAT must develop and deliver a valid and coherent plan which will identify what processes are being undertaken to prioritize commissioning of services.

2.3 In conclusion

International evidence shows that Methadone works and in the Scottish context it is entirely appropriate for methadone to hold a position as the major element of the treatment available for substance misuse.

In Scotland services have responded to a clear strategic direction, rapidly increasing demand and concerns around waiting times to increase accessibility to methadone treatment programmes. These services often aim to deliver harm reduction but may not address broader aspects of recovery effectively. This approach, though understandable, may have had a negative effect on the development of more comprehensive and integrated services and may also have reduced investment in alternative treatment approaches such as detoxification.

Scottish services struggle to demonstrate quality, consistency of practice and crucially outcomes achieved. There are examples of good practice but, in the absence of adequate audit information, local research implies that some elements of methadone prescribing are less effective than elsewhere in the UK. National data systems are inadequate and currently cannot address these concerns robustly.

Actions are required by the Scottish Executive, ADATs and NHS Boards and services themselves to ensure that the current gaps are filled and that commissioners and services are encouraged to deliver improved comprehensive services which can demonstrate their effectiveness in terms of both harm reduction and recovery.

Priorities for action include:

  • Developing a national strategic approach to the treatment of substance misuse
  • Improving the consistency and delivery of a national approach to substance misuse - addressing the perceived splits and inefficiencies between the Health and Justice Departments of the Scottish Executive.
  • Setting up a national accountability structure/body. This will deliver: increased ADAT empowerment and effectiveness; improved information; agreed quality standards; improved quality and range of services; an improved governance and accountability structure.
  • Setting up a national methadone audit process to quickly ascertain numbers on methadone and their current state of recovery
  • Supporting pilots of good practice in the areas of policies and procedures; clinical governance; standards and audit; information systems; processes of care; outcome measurement.
  • Setting up a strategic process to facilitate and coordinate quality research into methadone treatment in Scotland.