NTA

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HCC/NTA review and Hot topics

• Dr Emily Finch
• (ex) NTA Clinical Team Leader
• Consultant Addiction Psychiatrist, South London
  and Maudsley Foundation NHS Trust

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Summary

• HCC review 05-06, 06-07
• Prescribing audit
• New guidance to watch out for
• TOP

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Background to HCC improvement reviews

• Partnership of NTA and Healthcare Commission
• Move away from routine to targeted, proportionate
  reviews
• Aim to reduce the burden of inspection
• Follow-up for lowest scoring 10

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Assessment Framework

• Standards - from Standards for Better Health
• Criteria to judge if standards met
• 2 themes
• Care planning 6 criteria
• Prescribing 5 criteria

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Assessment Criteria for the Improvement Review

• Theme 1 Community prescribing services

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Assessment Criteria for the Improvement Review

• Theme 2 Care planning and care coordination

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Example Criterion 1 Commissioning of prescribing
services

• 7 elements that should be included in service
  level agreements and/or contracts. (from Models
  of Care)
• Definition of service (core)
• Description of services (core)
• Eligibility criteria (core)
• Aims and objectives
• Priority groups
• Exclusions and contradictions
• Policies and protocols

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Missing elements Comprehensive assessment

• The following elements were frequently missing
• 21 of services did not assess overdose history.
• 61 did not assess domestic violence history.
• 20 did not include a risk management plan, or a
  plan of how to ensure the risks identified in an
  assessment were addressed.
• 13 did not ask about contact with mental health
  services.
• 13 of services did not ask about alcohol use.
• 47 did not assess for symptoms of alcohol
  dependency.
• 19 did not record pregnancy.
• 52 did not assess for abscesses.

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Key Results Distribution of overall scores
across the local drug partnerships
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Total distribution of scores for each criteria
across community prescribing
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Headlines

• 26 no clinical audit in past 18 months
• 15 no supervised consumption at all
• 12 of local drug partnerships did not have a
  doctor with sufficient specialist training
  working within the local drug partnership area
• 49 of DATs had no contract for resi rehab, 33
  had none for inpatient detox
• 35 of people in structured services reported
  that they did not have a care plan (or didnt
  know if they did).
• 1/3 prescribing survey respondents reported no
  shared care

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National prescribing audit

• 2-part method
• 1. Questionnaire spring 05 -gt 66 response, 50K
  clients
• 2. PCA data (Prescription Cost Analysis)
• Findings
• Vast majority methadone was oral mixture (96.6)
• Significant underdosing both MMT and BMT
• MMT dose stable, longer term, BMT shorter,
  fluctuating
• 12 no bup at all
• 4 of total clients on benzos mostly diazepam,
  dose 4-192mg
• National trends
• Numbers rising, Doses rising, flexibility
  improved, safety improved

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Average doses of methadone for maintenance
prescribed by local drug partnerships
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Underdosing
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Recommendations

• 1. Clinical governance
• Assess practice against guidelines
• Good CG arrangements/framework
• Regular clinical audit
• 2. Review Service tools
• Assessment, including risk assessment
• Care planning
• 3. Follow up for lowest performers (10)
• Referred to SHA and regional NTA
• Action plan drawn up
• Assistance offered to draw up and deliver

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Next HCC review

• Already taken place - themes
• Harm minimisation
• Commissioning
• Data currently being cleaned
• NB..
• Shooting Up report rates of BBV
• NpSAD figures showing rise in DRDs

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Good practice briefings(due out April 07)

• Clinical governance
• Prescribing
• Care planning
• Less directly
• Non-medical prescribing
• Management alcohol problems in drug treatment

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Watch out for

• New Guidance Non-NTA national
• Clinical guidelines
• NICE
• Final versions Naltrexone, Meth vs Bup
• Consultation Psychosocial
• Consultation Detoxification

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NICE guidance psychosocial interventions

• Information/advice
• Choice rx, Service user-involvement in decisions
• Brief interventions
• Feedback, information, empathic manner
• Self-help NA, CA etc
• Contingency management
• 6 wks intensive toxi, vouchrs, 5 rising
  cumulatively
• reward length abstinence or BBV prevention
• Family-based interventions
• 12 wks, CBT style

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NICE guidance detoxification

• Client choice and assessment important
• Buprenorphine and methadone both effective. Use
  medication client is stable on
• Lofexidine for uncertain dependence, young
  people, those not wanting opiates
• No Clonidine or DHC
• Research on adjunctive medication
• No precipitated withdrawal or detox under
  anaesthesia
• Medically managed ip detox for severely
  dependent, medically monitored for less severe.
• Psychosocial interventions

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NICE technology appraisals methadone and
buprenorphine for maintenance

• Methadone and buprenorphine both recommended for
  maintenance
• Which drug to use should be made on a case by
  case basis,
• History of opioid dependence,
• Commitment to a particular long-term management
  strategy,
• Estimate of the risks and benefits
• If both equally suitable, methadone first choice.
• Supervision, for at least the first 3 months.
  Relaxed only when the patients compliance is
  assured.
• Both drugs should be given as part of a programme
  of supportive care.

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TOP - Outcomes monitoring

• New tool devised pilot underway
• Intended to be user friendly
• Quick
• Fit with care planning domains
• Report via NDTMS
• Validated, objective measures, scoring system
• Intended to be multipurpose
• Clinical tool for individual patient/keyworker
  discussions
• Service population analysis for services and
  commissioners
• National tool to demonstrate value of drug
  treatment

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Points for discussion

• What relevance have HCC findings for primary
  care?
• Can primary care implement NICE recommendations?
• What are the obstacles to using the TOP in
  primary care?
• .or anything else!