Short Life Working Group on Prescription Medicine Dependence and Withdrawal recommendations: Scottish Government response

Consultation

Draft recommendations were developed by the SLWG and provided to the Cabinet Secretary for Health and Sport who approved their publication by way of public consultation. The consultation paper discussed each of the PHE recommendations in turn, described the current landscape in Scotland, work that had been undertaken during the life of the SLWG and recommendations for further work agreed by the group and patient representatives. A summary of the PHE recommendations and SLWG Scottish Recommendations are shown in Table 1.

Table 1: PHE Recommendations and SLWG Scottish Recommendations

PHE Recommendation:

Recommendation 1 – "Increasing the availability and use of data on the prescribing of medicines that can cause dependence or withdrawal to support greater transparency and accountability and help ensure practice is consistent and in line with guidance."

SLWG Scottish Recommendations:

In line with National Statistics protocol, composition, and publication of statistics by Public Health Scotland will continue to be reviewed with consideration to user need. This will mean that clinical professionals and researchers can use the breadth of data and data indicators to improve patient care and treatment by evaluating interventions, measuring long-term outcomes in clinical trials, assessing the safety of new medical interventions and supporting the understanding of patterns of health and illness across the whole population. The suite of indicators and reports will be developed within STU to support front line practitioners identify patients that need review of their treatment.

PHE Recommendation:

Recommendation 2 – "Enhanced clinical guidance and the likelihood that it will be followed."

SLWG Scottish Recommendations:

A high priority recommendation of the SLWG is to take the antidepressant and gabapentinoid guides to conclusion, this will involve establishing expert groups, including patient representatives with lived experience, and building upon the scoping document.

SLWG are also recommending that Quality Prescribing Guides are developed for the remaining classes of drugs covered by the SLWG, opioids, Z-drugs, and benzodiazepines.

Scottish government will work to promote the utilisation of these guides through fostering collaboration across relevant health and other policy areas. The clinicians involved in the development of the Quality Prescribing Guides will use their networks to help ensure that the guides are used in practice and we will take their advice on what additional steps need to be taken to aid implementation of each guide using the data to drive change.

PHE Recommendation:

Recommendation 3 – "Improving information for patients and carers on prescribed medicines and other treatments, and increasing informed choice and shared decision making between clinicians and patients."

SLWG Scottish Recommendations:

Work with NHS Inform and NHS 24 to develop on-line guides and resources to support patients suffering from withdrawal from the 5 classes of medication covered by the review. There will be signposting to these resources from existing online content to ensure greater ease of accessibility and uptake. This will involve considering existing material produced for recreational drug use and put a team together to produce tailored guidance for each of the 5 classes of medication. The teams will include patient representation. Additional shared decision aids will be developed for the medicines covered by the SLWG and included within the polypharmacy app.

The free Polypharmacy: Manage Medicines app and website provide information and tools to support healthcare professionals, patients and carers in making decisions about taking multiple medicines. It contains two toolkits one for professionals and one for patients.

1. A toolkit for healthcare professionals

This provides quick and easy access at point of care to key recommendations from the national Polypharmacy Guidance including the 7-Step process for medicines review.

2. A toolkit for patients and carers taking multiple medicines

This provides information and shared decision support tools to support patients with self-management and shared decision-making between patients and professionals during consultation and medicines review. This toolkit will be expanded to include the medicines covered by the review

PHE Recommendation:

Recommendation 4 - "Improving the support available from the healthcare system for patients experiencing dependence on, or withdrawal from prescribed medicines."

SLWG Scottish Recommendations:

The SLWG agree that an out-of-hours helpline is required to help patients suffering from dependence and withdrawal from prescribed medicines as it is often out-of-hours when symptoms are most acute. Further scoping work should be undertaken on how the existing service provision can be boosted to take this requirement on board, this would include training for those staff who answer calls on behalf of the service. We have established an NHS24 synergies sub-group that will take this forward jointly with recommendation 3.

PHE Recommendation:

Recommendation 5 – "Further research on the prevention and treatment of dependence on, and withdrawal from, prescribed medicines."

SLWG Scottish Recommendations:

The Public Health England group came up with some proposals for further research. The SLWG considered these in a Scottish context and added some additional project proposals. It is hoped that some of these proposals will be adopted by academia and while Scottish Government will not commission these directly, we will consult with the Chief Scientist's Office on how these can best be promoted to relevant academic and other bodies.

Against each recommendation, the consultation asked 3 questions:

• Do you agree with this recommendation?;
• On a scale of 1-5, where 1 is not effective at all and 5 is extremely effective how effective do you think that action will be;
• Space for free-text comments.

There was overall strong agreement with the recommendations. Between 85% and 87% of respondents agreed with each recommendation and there was strong support that implementation of each recommendation would be either effective or somewhat effective. Table 2 shows the level of agreement against each of the 5 recommendations (represented in the table as "Rec").

Table 2: % agreement and level of effectiveness for each recommendation (Rec)

	Recommendation
	1	2	3	4	5
% agree with recommendation	87%	85%	87%	87%	87%
Level of effectiveness
Effective	46%	36%	38%	38%	41%
Somewhat effective	28%	33%	41%	38%	36%
Not effective	13%	18%	10%	13%	13%
Not answered	13%	13%	10%	10%	10%

Scottish Government officials undertook detailed qualitative analysis of the free-text comments, looking for themes, insights and opinions on the respondents' views of the consultation recommendations. Those identified included:

• The value of Data and Research, and the particular areas of interest respondents highlighted for further attention and focus.
• The need to consider not only how evidence and data are generated but also how that knowledge is implemented into practice through a process of knowledge mobilisation. Respondents highlighted some current issues with this process for existing data, and the need to alleviate the issue if future work is to be fruitful.
• The need for change in work culture/dynamics within the healthcare system. Respondents made reference to the need for greater communication with and between actors in the healthcare system, as well as improved communication and decision making between patients and practitioners.
• A few respondents commented on the need to better utilise existing resources such as community pharmacies and community pharmacists.
• Respondents also commented on the topic of patient experience and patient empowerment. These comments focused on the need to centre the patient experience in both data collection and research focus. In addition to the need for patients to be able to make informed decisions through a greater access to relevant information (particularly around the issue of withdrawal), as well as a more collaborative approach to the planning and decision making process of their individual health journey.
• Respondents discussed the need for suitable messaging with regards to guidance/information. Many respondents commented on the need to consider the accessibility of the guidance/data/information that the recommendations would make available. Accessibility in this context often referred to the ability of patients to have the means (either the physical IT resources, or the technical capacity to use said resources) to navigate to the required digital information and to ensure that alternatives were available in order to compensate for any potential disadvantages people may have in accessing this information.
• Many respondents commented on the issue of resourcing through the consultation. This typically revolved around discussion of the need for greater resources to be made available for the recommendations to be successfully implemented. Resourcing in this context could refer to issues such as additional staffing, additional funding, or addition time for people to consider the information available.