Clinical & Policy Updates:
SMMGP Policy Update June 2015
|Download the PDF version of this Update here! (PDF*, 231K)|
The Department of Health remit and priorities letter from Jane Ellison to Public Health England's Chief Executive Duncan Selbie sets out the role that the Government expects Public Health England (PHE) to play in the health and care system: PHE's first function is to protect the public's health. Its next function is to secure improvements to the public's health through its own actions and by supporting Government, local government and the NHS to secure the greatest gains in health through evidence-based interventions.
The letter sets out the priorities of PHE in the period from April 2015 to March 2016, including that the Government expects PHE to be an authoritative voice speaking for the public's health and ensuring that public health evidence is heard clearly as part of the policy debate. The Government acknowledges that this can include constructive mutual challenge between PHE and national Government, with PHE:
- providing evidence-based advice on which the Government will provide the national policy response;
- supporting local government in identifying its priorities for improving the health and well-being of local populations;
- acting as NHS England's public health advisor helping to ensure that the NHS secures the maximum health gain from its resources; and
- acting as a data provider and ensuring the provision of high-quality, record level data and analysis to users in local government the NHS and academia to support public health functions.
The letter further instructs that "(PHE) must play its part in promoting parity of esteem between physical and mental health by embedding mental health throughout its functions and business as usual activity".
The letter also sets out the Government's priorities for 2015/16 regarding "Improving the public's health". Relevant to the drug and alcohol treatment sector is the following:
- Reducing harmful drinking: Develop a whole system approach on alcohol that establishes what works and is clear on the return on investment, enabling Government, local government and the NHS to invest with confidence in evidence based prevention and treatment interventions.
- Improving the public's health: Continue to improve recovery rates for alcohol and drug treatment.
- Improving mental health and wellbeing: To underpin parity of esteem, support the development of the Mental Health Intelligence Network to create a transparent and effective benchmarking tool for Clinical Commissioning Groups and local authorities.
Another relevant bit in the remit letter to PHE reads as follows "PHE has an important role in developing and publishing the evidence base to allow faster progress on improving the public's health. The Government has commissioned PHE to review the evidence on what can be expected of the drug treatment & recovery system and provide advice to inform future policy".
We have asked PHE for more information about whether this latter piece of work (the review of the evidence) has been assigned and how it is to be approached, and await a response. In contrast to the more direct approach of the now long defunct National Treatment Agency, the dilution of PHE's Alcohol, Tobacco and Drugs division is readily apparent in our sector. Centrally PHE staff have been redeployed to work in teams spread across alcohol, drugs and tobacco and NTA Regional Teams were dissolved and the remains of that day have taken on other responsibilities in the PHE centres and drug treatment has slipped way down on the national agenda. With the demise of Drugscope, SMMGP is now the largest representative organisation nationally for those who work in the sector. Our membership has been growing exponentially and now numbers around 7000 made up of GPs, addiction psychiatrists, non-medical prescribers, providers, keyworkers, pharmacists and people across the spectrum of recovery. We believe that in the face of the current challenges, there is an urgent need for the sector to become more unified in order to represent itself and have high-level national influence.
Recent primary legislation announced by Iain Duncan Smith to strengthen the Child Poverty Measure includes a change to the definitions of child poverty. Key components of the new measure announced are:
- The proportion of children living in workless household as well as long-term workless households
- The educational attainment of all pupils and the most disadvantaged pupils at age 16
- A range of other measures and indicators of root causes of poverty, including family breakdown, debt and addiction.
It is worth noting that this legislation change was first mooted and consulted on back in 2012 and it would appear that the measures sought to be introduced at that time are now being implemented without further consultation. At the time of the 2012 consultation, in their joint response DrugScope, Adfam and Alcohol Concern urged caution with a caveat about the potential risks associated with introducing what may be perceived as a values-laden element that might further increase stigmatisation of people with histories of drug and/or alcohol use, including stigma in the labour market.
This Bill is currently being considered by Parliament and it has been widely criticised as being "poorly drafted and unenforceable in practice" as expressed too in this open letter.
The Government's Advisory Council on the Misuse of Drugs (ACMD) has also raised grave concerns about the draft Bill in that - if enacted without change - it "may include substances that are benign or even helpful to people including evidence based herbal remedies not included on the current exemption list". Amendments to the Bill are currently being heard.
Updated information on progress can be found on the Government website.
A recent report by the NAO notes that the government's PbR schemes are now estimated to account for at least £15 billion of public spending. However, neither the Cabinet Office nor the Treasury currently monitors how PbR is operating across government.
The government has "a growing portfolio" of PbR schemes where payment depends, at least in part, on the provider achieving outcomes specified by the commissioner. The NAO report looked at a number of areas where PbR is now used, including welfare to work, family support, offender rehabilitation, and international aid.
Experience to date has shown that PbR is a technically challenging form of contracting, not suited to all public services. But commissioners have often failed to explain why they have chosen to use PbR rather than alternative delivery mechanisms. The PbR mechanism carries costs and risks that government has often underestimated. Although PbR transfers some risk to the provider, commissioners need to be aware of the risks they retain: for example, that providers do not meet their objectives.
"While its supporters argue that, by its nature, Payment by Results offers value for money, these contracts are hard to get right, which generates risk and cost for commissioners. Payment by Results potentially offers benefits such as innovative solutions to intractable problems. If it can deliver these benefits, then the increased risk and cost may be justified, but this requires credible evidence. Without such evidence, commissioners may be using this mechanism in circumstances to which it is ill-suited, to the detriment of value for money."
The slide below captures what this means for drug treatment:
Making Every Adult Matter (MEAM) is a coalition of Clinks, Homeless Link and Mind formed to improve policy and services for people facing multiple needs. The image above was taken from "Interesting things that you may have missed" - a monthly roundup produced in an accessible blog post slideshare format by Andrew Brown for Making Every Adult Matter (MEAM).
The most recent edition features data on which groups with serious mental health problems are most vulnerable to crime, and how people with substance misuse problems present at hospital and A&E services, available here.
Good outcomes are immensely important in treatment services and any mechanism for supporting outcomes whilst obtaining value for money are worthy of careful consideration. PbR schemes also found their way to the drug and alcohol treatment sector and pilots were introduced. As outlined in the slide above, they failed to produce the desired results. The report warns of the dangers of continuing with PbR schemes in the light of the lack of a common source of shared expertise and a strong evidence base. In the drug treatment sector the continued emphasis on commissioning against "treatment completion" is perhaps at least in part a remnant of the ideals of "payments by results".
PHE have published a briefing with examples related to the Drug Strategy outcome of the capacity to be an effective and caring parent. The examples are offered to assist the development of local protocols to ensure that the children in households where drugs and alcohol use is a problem are protected from harm and that their welfare needs are met. The examples are not offered as best practice, rather for their interest and were selected in partnership with PHE centres and local authorities.
In both examples, multi-agency work is key as is to be expected. For early identification of alcohol misuse, the substance misuse service in Sheffield (Sheffield Health & Social Care NHS Foundation Trust, SHSC) via a web based screening tool enables workers from all children, adult and family services to:
- quickly screen for problematic alcohol use using a validated tool;
- provide clients with personalised brief advice using their own information from the screen;
- refer clients, with their consent, to the alcohol service immediately following the screen using an online tool.
Sheffield children's social care (CSC) now undertakes alcohol screening with parents/carers during assessment, a significant number of Sheffield GPs use the tool for new patients and it is used in community pharmacy settings, domestic abuse services, mental health and general hospital services.
In Lewisham, a trans-dermal alcohol bracelet is being piloted which measures alcohol within a parent's system 48 times per day. An evaluation report will be available shortly.
Detailed supporting documents on the development of local protocols between drug and alcohol treatment services and local safeguarding and family services are available on the NTA legacy website.
See http://tinyurl.com/IPEDbrief (pdf).
A PHE briefing in the 'Turning evidence into practice' series is for local commissioners who are responsible for commissioning services to prevent and treat harms caused by image and performance enhancing drugs (IPEDs) and injecting drug use. The content is drawn from published evidence, guidance, and expert consensus. It has been developed by a group of experts who are experienced in working with IPED users.
IPEDs include substances that promote weight loss, change skin colour, build muscle and allow longer, harder training. In this briefing, IPEDs refers to oral and injectable anabolic steroids and injectable ancillary drugs, typically taken alongside anabolic steroids (e.g. human growth hormone, melanotan, insulin and others).
The briefing provides an overview of the key issues that local commissioners and providers of services for IPED users should consider. The briefing covers various key topics (such as blood-borne viruses, poly-drug and alcohol use and outreach services), and provides prompts for each to help the commissioning of effective services for this group.
Free training, strategy development and practice improvement for local authorities
Adfam, the organisation for families and carers affected by addiction are offering local authorities the opportunity to work with them to help reduce the risks posed to children by opioid substitution medications. Since 2003, there have been 23 serious case reviews where OST medications were ingested by a child. Of these, 18 were fatal.
In April 2014 Adfam published a report "Medications in Treatment: Tackling the Risks to Children". The report examined cases where children had come to harm or died as a result of ingesting OST medications and made recommendations for policy and practice to address this risk. A year on, the writing of an updated report is underway, looking at the progress made in adopting the recommendations of the original report and highlighting good practice.
Adfam are offering local authorities across England and Wales an opportunity to help prevent these tragedies from happening again and by working with Adfam to implement best practice in safeguarding children from the risks posed by OST medications. To learn more, read the offer letter (PDF) available on the Adfam website.
The long-awaited changes to regulations to make naloxone more widely available were laid this week. For more information, see Amendment to Schedule 17.
The naloxone training provides education about naloxone and supports the distribution of naloxone to all who need it by including sections on how to use naloxone; who should be prescribed the medication, training, and what information people need in order to be prescribed naloxone.
It is free, open to all and takes approximately an hour to complete. As well as gaining CPD learning credit, you will receive a personalised Certification of Completion and automatic free membership of SMMGP (if you are not already a member).
Access all SMMGP's training courses on www.smmgp-elearning.org.uk
This e-learning module is an introduction to the Advanced Certificate in Community Management of Alcohol Use Disorders which aims to provide advanced learning for generalist and specialist primary care practitioners who work with people who have developed problems with alcohol.
The introductory e-learning module is open to anyone who wishes to learn more about management of alcohol use disorders, including how the commissioning process works. It will be of particular interest to GPs, nurses and pharmacists and other primary care practitioners. It is free, open to all and takes approximately an hour to complete. You will receive a personalised Certification of Completion and automatic free membership of SMMGP (if you are not already a member).
Access all SMMGP's training courses on www.smmgp-elearning.org.uk