Opioid Replacement Therapy – Independent Expert Group

Key findings and next steps – Quality Improvement

Key findings• Approaches to working with people with drug problems should ensure that substance

use is connected with wider work on health inequalities.

• Opiate replacement therapies are an essential treatment with a strong evidence base in reducing drug related harms (e.g. blood borne viruses and drug related crime).

• The delivery of opiate replacement therapies across Scotland is variable and there is a need to ensure that opiate replacement therapies are high quality.

• There is considerable variation in the delivery and development of recovery oriented systems of care (ROSC) across Scotland.

• Some good practice examples are identified in the report and these focus on the positive characteristics of what the report identifies as good practice in a prescribing service, GP service, residential rehabilitation team, a ROSC and data collection systems.

Key findings continued…• The involvement of primary care/ GPs is presented in the report as a challenge

• The report suggests a lack of progress in the delivery of recovery focused services and a lack of accountability and quality assurance of service delivery by Alcohol and Drug Partnerships (ADPs).

• The report suggests that current data collection systems for drug treatment are ineffective, do not provide timely information and are unable to capture outcomes. The report calls for the urgent development of meaningful information systems, which are subject to accountable project management.

• Research and academic enquiry into problem drug use in Scotland is described in the report as being poorly developed and underfunded. The reports calls for the Chief Scientist’s Office to develop and coordinate a national research programme on problem drug use.

Life expectancy trendsLife expectancy: Scotland & other Western European Countries, 1851-2005

Source: Human Mortality Database

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

1851

-185

3

1855

-185

7

1859

-186

1

1863

-186

5

1867

-186

9

1871

-187

3

1875

-187

7

1879

-188

1

1883

-188

5

1887

-188

9

1891

-189

3

1895

-189

7

1899

-190

1

1903

-190

5

1907

-190

9

1911

-191

3

1915

-191

7

1919

-192

1

1923

-192

5

1927

-192

9

1931

-193

3

1935

-193

7

1939

-194

1

1943

-194

5

1947

-194

9

1951

-195

3

1955

-195

7

1959

-196

1

1963

-196

5

1967

-196

9

1971

-197

3

1975

-197

7

1979

-198

1

1983

-198

5

1987

-198

9

1991

-199

3

1995

-199

7

1999

-200

1

2003

-200

5

Portugal

Scotland

Income deprivation - LiverpoolLiverpool LSOAs: income deprivation distribution

Source: DWP

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Total city: 24.6%

Income deprivation - GlasgowGlasgow merged DZs: income deprivation distribution

Source: GCPH, based on SIMD/DWP data

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Total city: 24.8%

All cause mortality males 15-44

Standardised mortality rates by cause, all ages: Glasgow relative to Liverpool & Manchester

All ages, both sexes: cause-specific standardised mortality ratios 2003-07, Glasgow relative to Liverpool & Manchester, standardised by age, sex and deprivation decile

Calculated from various sources

112.2 111.9126.7

248.5

131.7

168.0

229.5

0

50

100

150

200

250

300

350

All cancers(malignantneoplasms)

Circulatory system Lung cancer External causes Suicide (inc.undetermined intent)

Alcohol Drugs-relatedpoisonings

Sta

ndar

dise

d m

orta

lity

ratio

Source: Walsh D, Bendel N., Jones R, Hanlon P. It’s not ‘just deprivation’: why do equally deprived UK cities experience different health outcomes? Public Health, 2010

Man’s search for meaning

• “Those who have a 'why' to live, can bear with almost any 'how'.”

Viktor Frankl 1902-97

Workers in the 1950s

Implementing at scale….can it be done?

WillIdeas

Execution

1941, William A. Foster

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents

the wise choice of many alternatives.”

The six questions to be asked of EVERY change programme…

1AimIs there an agreed aim that is understood by everyone in the system?

2Correct ChangesAre we using our full knowledge to identify the right changes and prioritising those that are likely to have the biggest impact?

3Clear change methodDoes everyone know and understand the method(s) we will use to involve?

4MeasurementCan we measure and report progress on our improvement aim?

5Capacity and capabilityAre people and other resources deployed and being developed in the best way to enable improvement?

6Spread planHave we set out our plans for innovating, testing, implementing and sharing new learning to spread the improvement everywhere?

By what method?

W. Edwards Deming

The Typical Approach:

Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. Available: www.ihi.org p26

The Quality Improvement Approach:

Our change theory

A clear and stretch goal A method Predictive, iterative testing

Sep-0

5

Dec-0

5

Mar

-06

Jun-

06

Sep-0

6

Dec-0

6

Mar

-07

Jun-

07

Sep-0

7

Dec-0

7

Mar

-08

Jun-

08

Sep-0

8

Dec-0

8

Mar

-09

Jun-

09

Sep-0

9

Dec-0

9

Mar

-10

Jun-

10

Sep-1

0

Dec-1

0

Mar

-11

Jun-

11

Sep-1

1

Dec-1

1

Mar

-12

Jun-

12

Sep-1

2

Dec-1

20.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

0

10

20

30

40

50

60

70

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90

100

NHS FV ICU VAP incidence/% VAP Preventon bundle compliance Sept 05 - Dec 12

VA

P R

ate

/ 1

00

0 V

en

tila

tio

n d

ay

s

% V

AP

Pre

ve

nti

on

bu

nd

le c

om

-p

lia

nc

e

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Quarters

Sm

oo

thed

S

MR

Hospital Standardised Mortality Ratios (Seasonally Adjusted)Scotland: Oct-Dec 2002 to Jan-Mar 2012

average yearly reduction 4.2%

(Apr 2010 to Mar 2012)

1.4% average yearly reduction

(Oct 2002 to Jan 2010)

Breakthrough Series Collaborative

‘This model is not magic, but it is probably the most useful single

framework I have encountered in twenty years of my own work on

quality improvement’

Dr Donald M. BerwickFormer Administrator of the Centres for Medicare &

Medicaid Services Professor of Paediatrics and Health Care Policy

at the Harvard Medical School

The Model for Improvement

Reducing offending/reoffending

• Can you manage stressful situations?• How well can you manage your daily life?• Do you have access to external resources

which can support you in times of difficulty?• What gives you a sense of meaning and

purpose in life?

How has the frontline done it?

Get goalsGet boldGet togetherGet a model (and stick

with it)Get patients and

families

Get the factsGet to the fieldGet a clockGet the numbersGet the stories

What do you mean, “it’s a bit muddy”?

Do one brave thing today….then run like hell!