Clinical & Policy Updates:
SMMGP Policy Update January 2009
|Download the PDF version of this Update here! (PDF*, 114K)|
November's Policy Update is dedicated to the Department for Work and Pensions (DWP) Green Paper "No one written off: reforming welfare to reward responsibility" and your response to it. The paper attempts to set out plans for improving support and work incentives to create a system that rewards responsibility and delivers greater choice and control over the support that is provided.
In chapter 2 "An Obligation to Work" the DWP estimate that 240,000 people in England are in receipt of out-of-work benefits and are dependent on opiates or crack cocaine (problem drug users). This is around three-quarters of the estimated total number of people who are dependent on these drugs. The proposed plans could have a significant impact, potentially both positive and negative, on people who are "out-of-work" and claiming benefit, but for drug users it means a new regime.
The aim of the report is to highlight good practice in harm reduction based on interviews with local drug partnerships that performed well in the 2006/07 National Treatment Agency (NTA) and Healthcare Commission (HCC) service reviews, and to identify good practice in interventions to reduce drug-related harm related to blood- borne virus and overdose.
Drug-related deaths have gone down in recent years but by 2004 government targets had not been met. Harm reduction was selected as a priority for the 2006/07service review because of concerns about the increasing incidence of blood-borne viruses being recorded by the Health Protection Agency (2007) and failure to reach the government targets on drug related deaths.
Harm reduction combines work aimed directly at reducing the number of drug-related deaths and blood-borne virus infections, with wider goals of preventing drug misuse and of encouraging stabilisation in treatment and support for abstinence. Providing effective substitution treatments and effective support for abstinence are complementary aims of such a balanced response.
- Reducing Drug-Related Harm: An Action Plan (DH & NTA, 2007)
The 3-year programme of annual service reviews started in 2005 and is a key element of the NTA's aim to enhance the quality, consistency and effectiveness of drug treatment. Service reviews are designed to assess local drug services and systems against national standards. They provide the benchmark of the quality of drug treatment and provide information on areas of weakness, against which improvement can be planned. The 2006/07 reviews assessed the performance of 149 local drug partnerships on two key areas:
- Commissioning and systems management
- The provision of harm reduction services
Within these two themes, ten criteria were developed that were indicators for effective commissioning and harm reduction provision. Criteria 1-6 focused on commissioning and criteria 7-10 were developed to assess harm reduction interventions. Within each criterion there were a number of questions, the results are summarised in the graph below.
The NTA regional teams have used the results of the service review to inform their work with local drug partnerships, as part of the treatment planning process. In addition they interviewed partnerships that scored highly against the harm reduction criteria to find out about their strategies and practices in delivering harm reduction to determine what lessons could be learnt. Urban and rural partnerships and a variety of staff were interviewed, in order to identify a number of common themes that the partnerships believed contributed towards good practice. These are outlined below:
Key Factors Influencing Good Practice in Harm Reduction
Harm reduction embedded in the system
- Most local drug partnerships had harm reduction strategies that were developed and implemented by local expert groups.
- Partnerships reported that the availability of good quality local data was essential to assess the needs of their populations.
- Access to good drug treatment was essential to harm reduction, which in turn forms an integral part of a client's care plan.
- Harm reduction was specified as a standard in all contracts with drug treatment providers, to ensure harm reduction was delivered by these services.
- The involvement of service users in the planning, delivery and development of harm reduction services was seen as important. Many partnerships used forums and other feedback mechanisms as a check on the quality of the services provided.
- The interviewed partnerships described a range of interventions that were delivered across local drug treatment systems, including assessment, healthcare, needle exchange, blood-borne virus testing and treatment pathways, and services for steroid users.
Prompt and flexible access
Making access to harm reduction services easy as possible for clients was achieved in the interviewed partnerships through:
- Good coverage of specialist harm reduction services and pharmacies.
- Specialist harm reduction services and pharmacies being open outside office hours.
- Outreach services, such as vans and satellite clinics to reach clients outside the treatment system.
- Delivering a range of interventions in pharmacies including:
- distributing injecting equipment and other injecting paraphernalia;
- pharmacy staff referring clients to appropriate specialist harm reduction service;
- drugs workers working in pharmacies to provide brief harm reduction interventions.
- All partnerships placed a high priority on testing for blood- borne viruses, with most aiming to test as many clients as possible and address blood-borne virus issues at initial assessment.
- Most partnerships reported offering hepatitis A and B vaccinations. Vaccinations were usually carried out by nurses in specialist harm reduction services or other drug treatment services.
- Hepatitis C treatment pathways were established in most of the areas interviewed.
Action to reduce deaths from overdose
- Most had a strategy for reducing drug-related overdose deaths and some partnerships had joined up with neighbouring partnerships to have a wider strategic focus.
- All provided overdose training for service users and carers.
- Some had established enquiry processes for drug-related deaths.
- Most had plans in place to minimise the overdose risk for those leaving prison in their areas.
- Many areas had done proactive work on drug-related death prevention.
- Harm reduction training was standard for all drug treatment staff.
- The harm reduction competencies of non-treatment staff working with drug users was also addressed through multi-disciplinary training.
- Most areas had training programmes for pharmacy staff in contact with drug users to improve their skills and knowledge.
- All partnerships employed staff in co-ordination roles to co-ordinate harm reduction services.
- Many partnerships had run campaigns to achieve high returns of injecting equipment.
- Harm reduction interventions were also delivered in non-drug treatment settings.
Community prescribing services
Community prescribing services were assessed as providing, in the main, a good range of harm reduction initiatives. However the interviews reflected that even in the partnerships that are performing well improvements were needed in the following areas:
- Vaccination for hepatitis B and testing and treatment for hepatitis C were not provided widely enough by local drug treatment systems. Almost all partnerships had less than 75% of their service users being offered a hepatitis B vaccination and 29% did not have a protocol relating to hepatitis B. Worryingly less than 50% of service users had a recorded test date for hepatitis C.
- Nearly half the service users surveyed thought that the harm reduction services they received were not comprehensive enough.
- One particularly weak area was out-of-hours needle exchange services with only 2% of areas interviewed having services on Sunday.
- Local partnerships have made significant progress in developing systems to reduce drug-related deaths but more needs to be done. Over 30% of areas did not have a multi-agency plan on reducing drug related deaths. Naloxone training for paramedics was common but no areas interviewed had take-home naloxone available.
This is an important report and it's great that harm reduction has been given prominence by the NTA and the HCC. There are useful examples of good practice highlighted in the report. It's pleasing that we are getting some things right but there is still work to be done. The recognition of the importance of service user involvement in planning and delivering harm reduction services and how this can effect change in services is refreshing and a vital point.
Although there are examples of good practice there are still many improvements to be made concerning services for hepatitis B and C and reducing drug-related deaths. We need to ensure that all our patients have access to testing and vaccinations and that they are competent to manage their own and other's overdoses.