Does Evidence Based Training have an impact on treatment outcomes for patients

1
Does Evidence Based Training have an impact on
treatment outcomes for patients?

• Jo Betterton
• Manager
• RCGP Substance Misuse Unit

2
The extent of the problem in England

• An estimated 250,000 300, 000 problematic drug
  users in England requiring treatment (Home
  Office)
• Studies consistently show that England and
  Scotland have among the highest illegal drug use
  in the western world
• 34 of all Hepatitis B in England is associated
  with drug use
• Over 90 of Hepatitis C in England is associated
  with drug use
• Recorded rates of drug related death from
  overdose in the UK are among the highest in
  Europe
• (The 2007 Department of Health Drug Misuse and
  Dependence UK Guidelines on clinical management)

3
Background

• Policy driven Tackling Drugs to Build a Better
  Britain Government Drug Strategy (HMSO 1998)
  with a target of 30 of GPs to be prescribing
• Establishment of National Treatment Agency in
  2001 the special health authority to improve
  the availability, capacity and effectiveness for
  drug misuse in England
• An acknowledged reluctance by GPs to take this
  work on because of lack of skills and training
  (Gerada Farrell )

4
Concerns about the standard of GP treatment being
provided

• Much of the prescribing of methadone was at were
  sub-optimal levels
• Widespread disregard for supervised or interval
  consumption schemes
• High levels of diversion, black market sales and
  potential deaths from overdose
• Large geographical variations in GP treatment
  availability
• (Strang et al BJGP June 2005 , Hunt Strang
  NTA Research Briefing 29, June 2005)

5
The plan in 2002

• Establish a multi-agency, inter-collegic working
  party to develop a training package
• Encourage wide participation
• De-mystify working with drug users
• Promote good standards of care
• Work towards main streaming primary care
  provision of treatment for drug misusers

6
What were the original aims?

• Enable GPs to be competent to practice at the
  specialised generalist level as outlined in the
  1999 Department of Health Clinical Guidelines on
  Drug Misuse
• Develop the role of GPs in local strategic
  planning, commissioning and shared care
  monitoring groups
• Create a cadre of General Practitioners with a
  Special Interest who would improve standards in
  primary and secondary care.

7
Who

• The Royal College of General Practitioners
• The Royal College of Psychiatrists
• Royal College of Nursing
• Royal Pharmaceutical Society Great Britain
• Department of Health
• Department of Health Prison Health
• National Treatment Agency
• Voluntary Sector
• Service User Organizations

8
The Skills Escalator

• Vocational Training Certificate1
  Certificate 2 Further postgraduate
• Training and defined leadership role

9
DANOSDrug and Alcohol National Occupational
Standards

• DANOS the Drugs and Alcohol National
  Occupational Standards specify the standards of
  performance that people in the drugs and alcohol
  field should be working to. They also describe
  the knowledge and skills workers need in order to
  perform to the required standard.
• Used in a very straightforward way, DANOS
  standards allow individual workers to be
  perfectly clear about what is expected of them in
  their work. Workers can check that they are doing
  a good job. They can also identify any knowledge
  they need to acquire or skills they need to
  develop.
• www.skillsforhealth.org.uk

10
What do we do?

• Introduced a training programme for Primary
  Health care providers providing treatment for
  substance misusers
• Certificate in the management of drug misuse
  Part One
• Certificate in the management of drug misuse
  Part Two
• Advanced Secure Environments Module for the
  secure environments staff
• Ongoing refresher CPD days
• Guidance documents for primary care practitioners

11
What evidence?

• Guidelines for the appointment of General
  Practitioners with Special Interests in the
  Delivery of Clinical Services Drug Misuse Royal
  College of General Practitioners and Department
  of Health (May 2002)
• Department of Health/ Royal College of General
  Practitioners Implementing a Scheme for General
  Practitioners with Special Interests (April 2002)
  
• Implementing a Scheme for General Practitioners
  with special interests. A paper prepared on
  behalf of The Royal College of General
  Practitioners and the Royal College of Physicians
  of London (May 2001)
• Guidance on Good Medical Practice GMC
• Good Medical Practice for General Practitioners
  RCGP General Practitioners Committee (2002)
• Roles and responsibilities of doctors in the
  provision of treatment for drug and alcohol
  Misusers (RCPsych, RCGP 2005)
• Implementing Care Closer to Home providing
  convenient quality care for patients. A national
  framework for Pharmacists with Special Interest.
  Department of Health (September 2006)
• Drug and National Occupational Standards (DANOS)
• Models of care for treatment of adult drug users
  update 2006 (NTA 2006)
• Implementing care closer to home Convenient
  quality care for patients. Part 3 The
  accreditation of GPs and Pharmacists with Special
  Interests (DH 2007)
• Implementing a scheme for Nurses with Special
  Interests in Primary Care. Liberating the talents
  (DH April 2003)
• Implementing Agenda for Change for NHS
  Contractors Staff in England. A best practice
  guide, Department of Health 2004).
• Drug misuse and dependence UK guidelines on
  clinical management 2007,
• Good practice in care Planning NTA (2007)
• QuADS Quality in Alcohol and Drug Services
  Organizational Standards for Alcohol and Drug
  Treatment Services. Alcohol Concern, SCODA (1999)
• Maintaining competency in prescribing. An outline
  framework to help pharmacist prescribers (NPC
  October 2006)
• Maintaining competency in prescribing an
  outline framework to help nurse supplementary
  prescribers (NPC March 2003).
• The toolkit for General Practitioners and Primary
  Care Organisations Criteria, Standards and
  Evidence Required for Practitioners Working with
  Drug Users
• - National Institute for Health and Clinical
  Excellence publications and guidance

12
Part One

• Aimed at practitioners working at a generalist
  level
• Mapped To DANOS
• Endorsed by NTA
• 2 e-modules (free to all)
• 1 day face-to-face event

13
Part Two

• Aimed at Practitioners with a special interest
• 9 days study spread over a 6 month period
• Includes log book record of treatment
  interactions, critical appraisal of research,
  audit of own practice, and attendance at tutor
  lead teaching sessions
• Portfolio of work submitted to an RCGP approved
  Assessment Board

14
Advanced Secure Environments Module

• Two day course supplements the learning offered
  by RCGP Cert 1 and 2 , offering further specific
  skills and knowledge to ensure confidence, safety
  and governance in executing ones clinical duties
  in respect of substance misusers in the secure
  environment setting
• Aimed at
• - Safer custody prison staff
• - Substance misuse and primary care nurses
• - CARATs Teams
• - Prison doctors/GPs

15
Guidance Documents
16
Numbers who have completed

• Part One 7,000
• (since 2004)
• Part Two 1,523
• (between 2001 -2007)
• Advanced Secure 200
• Environments Module
• (since 2007)

17
Feedback from Part Two Candidates

• External evaluation of the course by the National
  Adicition Centre on the first year cohort.
• 331 GPs started and 290 successfully completed
  that year.
• Pre and post course questionnaire , using Likert
  Scale (very poor to very good) asking them to
  rate how the course impacted on the following
  four areas
• Knowledge
• Attitudes
• Clinical Practice
• Confidence
• Claire Hunt John Strang Evaluation of the 1st
  English cohort of GPs attending the RCGP
  Certificate in the Management of Drug Misuse
  Final report to the RCGP produced 2004

18

• Knowledge - 48 reported that the course had
  impacted quite a lot on their knowledge
• 56 reported that their knowledge was fairly
  good at the start , which rose to 61 rating
  their knowledge as good by the end
• Attitudes - 2/3rd of the cohort felt that their
  attitude was positive at the start of the course
• 24 felt the course had impacted quite a lot on
  their attitude
• Clinical Practice 45 reported that the course
  had influenced the quality of care they provided
  quite a lot
• At the start of the course 54 reported that the
  standard of care they provided was good and this
  increased to 61 after the course
• Confidence -44 felt that the course had improved
  their confidence
• At the start of the course 53 reported feeling
  quite confident and at the end of the course 59
  reported feeling confident.

19
Further Evidence
20
Health Improvement Reviews

• Joint reviews carried out by The Health Care
  Commission and the National Treatment Agency
  under Community Health Standards Act 2003
• Carried out a review of drug treatment centres or
  services provided by voluntary and independent
  sector providers
• Health Care Commission have statutory remit to
  review services and NTA provided specialist
  knowledge
• 2005/6 Care planning and prescribing
• 2006/7 Commissioning systems and harm reduction
• 2007/8 Diversity and theraputic services
• Targeted the bottom 12.5 and supported them to
  develop and implement an improvement plan
• Reference BD 2/2006/14 HCC/NTA Improvement
  Review 2005/6

21
The picture now

• Number in treatment in England increased from
  85,000 to 202, 000 (138 increase)
• 78 of people starting treatment in 2007/8
  remained in structured treatment for 12 weeks
• Number of people successfully completing
  treatment in 2007/8 was 35,000 (51 of all
  discharges during that period)
• Waiting times for treatment reduced from an
  average of 9 weeks in 2001 to 3 weeks in 2008
• Average Methadone dose risen from 30ml to 60mls
• In 1998 estimated between 1076 and 2997 DRDs in
  2005 recorded as 1, 827 DRD

22
Primary Care input

• In 1995 estimated that only 3 of GPs were
  prescribing for substance misusers
• In 2005 estimated that 31 GPs were prescribing
• Substance misuse treartment is incorporated into
  the new GP contract as part of Locally Enhanced
  Services
• Outcome monitored
• Jim Barnard SMMGP www.smmgp.org.uk/

23
Summary

• The NTA produced statistic all indicate an
  improvement in treatment options, retention in
  treatment and reduction in drug related deaths
• The Certificate Part One and Part Two are the
  only training programs referenced in the DH
  Clinical Guidelines, and commissioners are asked
  to report how many people are trained to these
  levels as part of the NTA monitoring
• The RCGP training program has become the
  recognized training program and is built into
  workforce planning and commissioning standards
• The course has become a minimum standard for
  practitioners delivering shared care treatment
  for substance misusers.
• The increase in numbers of GP providing evidence
  based treatment has helped to reduce the waiting
  lists in secondary care.

24

• The whole systems approach undertaken by the
  Department of Health has contributed to the
  overall improvement in drug treatment
• The joint working between the various
  professional groups had supported these
  developments.
• The successes are down to the improved training
  available, combined with outcome monitoring and
  guidance in the commissioning of services.