Powerpoint Presentation by Mark Harrison
Minutes:
The board received a presentation with an update of the clinical audit into the prescribing practises of GPs under contract with the Council to deliver substance misuse treatment. The board were advised that the scope of the review was to also provide advice to the Council in relation to potential substance misuse service redesign,offer clinical advice as appropriate and to undertake targeted consultation for specific elements of the process.
A summary of system wide observations was provided – these were as follows:
Engagement:
· A number of instances identified of direct access to ‘shared care’ via primary care
· Access to individuals within Primary Care is extremely variable
· Outreach provision, is fairly limited and poorly attended
· Recovery visibility is not evident within Primary Care settings
· The pathways and referral processes for anything other than ‘traditional’ medical treatments need to be redesigned and wherever possible simplified/publicised
Treatment:
· A general feeling that ‘navigation’ was difficult in terms of the right service managing the care of specific individuals to best meet their identified needs
· In terms of providing medical support, shared care was working well in relation to the retention of individuals, although there was limited evidence of arrangements being ‘plugged into’ community assets
· A proactive approach existed to get people into treatment and onto Opioid Substitution Treatment
· The enhanced Enhanced Psychological Intervention programmes, were both well considered and delivered by experienced practitioners, but groups during the review were poorly attended
Recovery:
· There appears to be a slight clash of cultures and an absence, in respect of a shared understanding of recovery ambition
· High numbers within Shared Care were reported to be ‘using on top’ of prescription
· Payments for shared care weighted in favour of retention in treatment and receipt of medication rather than recovery from their addiction, reduction in drug/alcohol use
· Wider issues exist, such as poor recovery environment, particularly within primary care settings
Governance:
· There was a perceived absence of clinical leadership
· There is marked variation in practice across the treatment system
· Some practices have only one Dr., who may be providing services to significant numbers, without any contingency plan in place
· Primary Care treatment element is captured on a variety of systems with ‘periodic’ review by CGL workers and then elements manually input into CRiiS
A graph showing the numbers of drug clients in primary care by practice was displayed – it was noted that the Teams area has the highest number of patients. Observations show that areas with high demand for these services are often those areas with the most experienced staff. However, it was also noted that whilst there are a significant number of experienced GPs delivering specialist clinical services within primary care, some GPs have had less exposure to appropriate quality training and support, making for an inconsistent approach across Gateshead.
The board were advised that, in general, GPs had very little understanding of potential recovery and tended to subscribe to traditional harm reduction approaches. Further observations were delivered to the board, these were:
· There is currently no way of centrally determining range of dosage, but there is some anecdotal high levels of methadone prescribing, as well as prescribing of other ‘abusable’ medication e.g. Gabapentin, Benzodiazepines and Pregabalin.
· A particular concern is the prescribing of Methadone in various high strength forms
· Testing and supervision arrangements are extremely varied
· Supervised consumption appears to be used appropriately within initial stages, but not always reviewed either frequently or systematically
· There remains ‘pitiful’ coverage in some areas, which require support e.g. Chopwell
An analysis based on the review was summarised outlining strengths, weaknesses, opportunities and threats. It was noted that these findings would support with future priority setting.
The board were advised of the post audit considerations which were:
· Public Health’s commitment to future review of shared care element following previous recommissioning and system changes
· The release of National Drug Strategy and UK Clinical Guidance
· The need to take immediate action on identified safety and governance issues.
· Opportunity to ‘harmonise’ contract end dates and consider ‘whole system’
· Recognition that recommissioning of shared care element in isolation, would provide limited incremental improvement, but limits opportunity to take next ‘logical steps’ towards an enhanced treatment system
· Recommissioning of the whole system would provide greater opportunities to go ‘faster and further’ in the realization of high quality and efficient service provision, allowing for greater enhanced outcomes for individuals, families and communities
· Whilst the primary objective in undertaking the option of recommissioning services would be to increase performance, quality and positive outcomes for Gateshead residents, opportunities for efficiencies could be explored, quantified and reviewed in line with developing budget options for 2018-2020
A concern about the long term prescribing of methadone was raised. It was noted that the numbers of individuals who are successful in coming off methadone are not as visible due to the scale of long term prescribing. It was said that the recovery orientated approach was welcomed and that those who come off methadone could be used as mentors.
The board were advised that the peer support model is being used going forward, that recovery isn’t sufficiently visible in primary care and that work is ongoing to improve this. It was also noted that the peer recovery model should be used system wide and that GP’s should be educated to see that recovery is possible. It was noted that prescribing opiates is an enhanced service offered by some GPs and that not all GPs offer such a service.
A comment was made that recovery is often a very long term goal for patients. Factors such as having chaotic lifestyles and financial problems can affect the chances of recovery for many individuals and this is why methadone is prescribed long term. It was noted that enhanced training for those delivering services in primary care can also support patients in other areas when necessary.
It was noted that there is data showing individuals making use of other services to support their recovery. Evidence shows a variation in experiences across Gateshead and this needs to be more balanced. It was also noted that there is to be a broad consultation to deliver a more holistic model and that services need to be more ambitious about supporting this demographic.
RESOLVED
(i) That the Health and Wellbeing Board note the findings of the Shared Care Audit.