12 - MAT Standards
North Ayrshire Council · 25 August 2022
Back to Integration Joint Board — 25 August 2022 and its agenda
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Integration Joint Board 25th August 2022 Subject : North Ayrshire HSCP & ADP Implementing Medication Assisted Treatment - Annual Report Purpose : To present information on the implementation of new Medication Assisted Treatment (MAT) Standards and for the IJB to be aware of the next steps in delivering MAT and the obligations required from Chief Officers and Chief Executives Recommendation : IJB are asked to note the content of the accompanying report IJB are also asked to note and act on the obligations contained within recent correspondence from the Minister for Drugs Policy which details specific governance and accountability responsibilities for Chief Officers and Chief Executives Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required X 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms IJB Integrated Joint Board HSCP Health and Social Care Partnership ADP Alcohol and Drug Partnership MAT Medication Assisted Treatment DRD Drug Related Death MIST MAT Implementation Support Team 1. EXECUTIVE SUMMARY 1.1 To present a report North Ayrshire HSCP and ADP on the implementation of new MAT Standards for management and assurance purposes and to provide information on the requirement of a new North Ayrshire MAT Improvement Plan which is to be personally signed off by the end of September by Chief Officers and Chief Executives
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2. BACKGROUND 2.1 The MAT standards are one of the platforms for successful delivery of the National Mission to save and improve lives in response to Scotland’s drug deaths crisis. The standards enshrine a rights-based approach to immediate, person-centred treatment for problem drug use, linked to primary care, mental health and other support services. OVER SERVICE (NAD The accompanying report (Appendix 1 - ‘MAT annual summary report’) provides information from April 2021 to March 2022 on the implementation and progress on initiating MAT delivery in North Ayrshire. Appendix 2 provides detail of the RAG status for each of MAT Standards 1-5 for each ADP area. NHS Ayrshire and Arran are well placed in terms of progress. 3. PROPOSALS IJB are asked to note the information included in the accompanying report in relation to: • The processes involved in the introduction of MAT delivery; • The Test of Change process and the positive impact of this • The improvement in access times to commencing treatment that supports an individual’s recovery; • Data on MAT delivery; • Client experience and case studies • Staff experience The IJB are also asked to note the information contained in (Appendix 3 - North Ayrshire Assessment of progress by MIST July 2022. The report provides an overview of the MIST’s assessment of MAT implementation in North Ayrshire and also provides a number of Improvement Actions to be included in a new North Ayrshire MAT Improvement Plan. In addition, the IJB are asked to note the obligations contained within recent correspondence from the Minister for Drugs Policy (Appendix 4) – namely: ‘Ministers will expect the following actions to be taken and oversight arrangements in place in each local area: a) That, by the end of September, Chief Officers and Chief Executives personally sign timed, specific and published Improvement Plans for implementing the standards – to include the delivery recommendations being made locally with MIST which are to be published by PHS on 2 August; b) The Improvement Plans and the reporting on progress must involve and include the voices of those with lived and living experience. It will be for each local area to determine what arrangements it needs to have in place to ensure this is done,
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potentially drawing on MIST lived experience support, from third sector partners or from their own local forums or panels; c) That Chief Officers and Chief Executives take shared and visible responsibility for delivering the standards (with the Chief Officer being responsible for overall delivery and the Chief Executives committing to support them). This requirement should align with on-going work to define and refine local governance and accountability over alcohol and drug services; d) That Chief Officers and Chief Executives include reports on progress as part of the regular Board quarterly reporting against Annual Delivery Plans (the first report in this series is due in July 2022); e) Health Boards, Integration Authorities and local authorities are to identify a senior leader for each Integration Authority area as the single point of operational responsibility for driving the changes necessary; f) Should any quarterly report identify the need for intervention, that this is acted on immediately ‘. 3.2 Anticipated Outcomes The implementation of the MAT Standards is part of a wider range of interventions with the desired outcome of preventing Drug Related Deaths (DRD) and offering more timely and appropriate treatment to support an individual’s recovery. 3.3 Measuring Impact These Standards are now part of a continuous implementation, review, monitoring and improvement cycle delivered by local services whilst being supported by the national MAT Implementation Support Team (MIST) in line with Scottish Government priories in relation to the prevention of DRD’s. The agreed Improvement Plan will guide services to ensure that MAT standards 1 to 5 are fully implemented by April 2023 and that Standards 6 to 10 are, at least, partially embedded by April 2023 4. IMPLICATIONS 4.1 Financial Additional funding to support the initial implementation of MAT delivery has been sought and approved from both the ADP and the Scottish Government (however, this funding was only confirmed in July 2022). 4.2 Human Resources A wide range of staff from across the HSCP, ADP and partner services are involved in the delivery and evaluation of these MAT Standards.
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4.3 Legal Detailed within the correspondence from the Minister for Drugs Policy, although not detailing a legal require, there is reference to a clear expectation that actions will be taken and oversight arrangements are put in place in local area. 4.4 Equality/Socio-Economic The full implementation of the MAT Standards will have a direct positive impact on some of the most vulnerable members of society. 4.5 Risk Staff recruitment continues to be an issue and the availability of premises in locality areas to undertake the full range of MAT interventions. 4.6 Community Wealth Building N/A 4.7 Key Priorities The implementation of these Standards is a key Scottish Government priority to support the delivery of local strategic and operational plans across statutory and partner services and support wider actions to prevent Drug Related Deaths in line with the National Mission 5. CONSULTATION Staff and service users from across various services have contributed to the production of this report. Director – Caroline Cameron For more information please contact Thelma Bowers, Head of Mental Health on [01294 317763 or thelmabowers@north-ayrshire.gov.uk] Appendices • Appendix 1 - MAT annual summary report • Appendix 2 – Implementation Status – National Picture • Appendix 3 - North Ayrshire Assessment of progress by MIST July 2022’ • Appendix 4 - Correspondence from the Minister for Drugs Policy - MAT
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Aim: To have no barriers to accessing treatment and care that supports an individual’s recovery. This project focussed specifically on improving access to appropriate Medication Assisted Treatment (MAT) in order to prevent deaths, reduce harms and promote recovery opportunities. IMPLEMENTING MEDICATION ASSISTED TREATMENT (MAT) NORTH AYRSHIRE DRUG AND ALCOHOL RECOVERY SERVICE (NADARS) Reporting period: 1st April 2021 - 31st March 2022 Quality issue: The numbers of drug related deaths in Scotland continue to increase. In 2020, there were 1,339 drug related deaths, which is the largest number ever recorded and an increase on the previous year. Ayrshire and Arran have the second highest death rate per 100,000 population. Evidence suggests quick access to treatment is crucial and being in treatment can be a protective factor for majority of individuals. The Scottish Drug Deaths Taskforce (SDDTF) has prioritised the introduction of the MAT standards to help reduce the number of drug related deaths. There is evidence that rapid access to MAT meets the needs of highly vulnerable groups and reduces mortality. Measurement of improvement Tests of change Effects of change: Cycle 1: Implement and Test the MAT clinic pathway on a Monday and a Thursday in one locality (Three Towns). Cycle 2: Secure funding to recruit staff to support the implementation of the full model. Cycle 3: Refine project charter to facilitate full model (in progress and now upscaling towards full model) Cycle 4: Expand service to 5 days per week across all of North Ayrshire. Improvement in the waiting time from point of referral to commencement of appropriate Opiate Substitution Therapy medication - average time from assessment to prescribed medication reduced from 21 days to 1 day (from pilot period to current date). Improvement in satisfaction and experience of clients. All individuals received a mental health assessment and support as required. All individuals were offered Blood Borne Virus (BBV) testing, Harm Reduction interventions, physical health assessment and referred on for further support where required. All individuals had the opportunity to access Recovery Development Worker's with lived experience to provide person centred recovery support. All individuals had the opportunity of family involvement. All individuals were offered housing, advocacy support and were referred for social care support where appropriate. There were no unplanned discharges within the reporting period.
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0 5 10 15 20 25 0-24 35-44 55+ IMPLEMENTING MEDICATION ASSISTED TREATMENT (MAT) NORTH AYRSHIRE DRUG AND ALCOHOL RECOVERY SERVICE (NADARS) Annual summary: 1st April 2021 - 31st March 2022 REFERRALS BY GENDER REFERRALS BY GENDER AND AGE GROUP COMMENCED MAT SAME DAY/NEXT DAY (where clinically appropriate and safe) FEMALES MALES 41 43% 55 57% 79% OPIOID SUBSTITUTION MEDICATIONS PRESCRIBED FOLLOWING ASSESSMENT ESPRANOR METHADONE 19 61 78% NALOXONE AND OVERDOSE AWARENESS Of clients were supplied with Naloxone **The remaining 22% declined or already had a kit ** INTERVENTIONS OFFERED AT POINT OF MAT DELIVERY Of clients were offered Mental Health Support and harm reduction interventions including BBV testing, IEP and Sexual Health 100% CLIENT EXPERIENCE INDIVIDUALS IDENTIFIED AS HIGHER RISK * 10% Of clients were identified as at higher risk at point of assessment (and received additional support) *as defined by the MIST/MAT reporting criteria* Of clients commenced MAT on same day or next day from assessment 100% Of clients were offered Naloxone ** individuals were given a short term methadone prescription to stabilise before being transferred to Espranor** client changed their mind client went to prison not ready to commence MAT but continued to receive support from the wider service. 96 clients chose this pathway of support. Following assessment 80 agreed to commence. Reasons for not commencing the pathway were: 100% 100% of clients felt that they were given sufficient information to make an informed choice on their treatment options 100% of clients who were able to commence their medication at their initial appointment stated that there were no delays in getting their prescription 100% of clients felt that the NADARS worker explained all the care and treatment options in a way that they understood 100% of clients rated the overall service "excellent" or "very good" 100% of clients rated their initial assessment either "excellent" or "very good" of clients rated the communication from NADARS either "excellent" or "very good
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CASE STUDIES Case study 1 Case study 2 A 38 year old female was referred to NADARS in October and assessed via the MAT pathway. The client wished to be commenced on OST to allow her to gain stability from illicit heroin use. The client was commenced on Espranor. Since being commenced on OST, the client has had two significant lapses, however, with support from her key worker, has been able to identify triggers and worked on functional alternatives to drug use, to enable stability and reduce the risk of further lapses in the future. The client has now been abstinent from all illicit substances since December 2021. She has been able to recognise the marked improvement in her mental health since becoming abstinent and is using this as motivation to continue. The client is now attending many different community recovery groups and is linked in with the Recovery Development Workers for extra support. In the long term, the client is hopeful that by maintaining stability, this will allow her to have more contact with her child. Service information Client referred into NADARS 27/05/2021. Assessed on 31/05/2021 and ORT prescription was commenced on 01/06/2021. Client was seen at least weekly and had regular telephone support in between face to face appointments. Client was offered interventions from NADARS Health Addiction Nurses for specialist input and BBV testing. Client was transferred from MAT Clinic into regular locality for allocation of new keyworker. Client Feedback It was really fast getting put onto a prescription at first which was so much better than having to wait for weeks. I got lots of support with my workers and appointments. It made things easier to reduce my heroin use. I did well for first few weeks but started injecting again and taking other drugs around 2 months into treatment. I was linked in with the peers and this helped by going to meetings and having regular keyworker support. I have now been stable on my prescription for a long time and I feel in control of my recovery. My worker is supportive and my dispensing has been reduced and this helps me with my mobility. I am in a new relationship now and my partner is supportive of my recovery. I no longer attend the group meetings but I have rebuilt my relationships with my family and I want to continue to remain stable and look at reductions to my prescribed medication in the next few weeks. Case study 3 23 year old female referred by NADARS social care addictions worker on 28/09/21 and appointment accepted via NADARS MAT (Medication Assisted Treatment) clinic on 30/09/21, for rapid access to OST (Opiate Substitution Therapy). Client reported history of alcohol and illicit substance use including; heroin, benzodiazepines, cocaine and pregabalin. Previously admitted to ward 5, Woodland View for inpatient detox in April 2021; however, had taken early self-discharge. Not previously engaged with OST. Client's goal to regain abstinence from all substances and alcohol. Wishing to achieve this via OST, preference for espranor, and engaging with support. Client was assessed by the staff nurse and consultant psychiatrist as planned on 30/09/21. Reported to have been snorting heroin sporadically over the last year and in recent months had increased to once or twice week. However, over the last few weeks this had increased further to around 2 bags daily and change of route to smoking. Also reported use of illicitly diverted prescription grade espranor, being used nasally. Further reported significant but unspecified amounts of street tablet use, as well as crack cocaine use. Current supports in place via criminal justice, SHINE, Housing First and Money Matters. Significant offending behaviour and complex mental health issues. Client was commenced on a 5 day methadone prescription (30ml daily supervised) with plan for transition to espranor medication. Client then opted to remain on methadone prescription rather than transferring to espranor. Client engaged with MAT clinic appointments for a 6 week period prior to her care being transferred to a key worker within the wider team. Client is now abstinent from illicit substances and engaging with supports.
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Staff buy in to complete systems and follow processes . Systems require to be fit for purpose for data recording. Buy in from staff. Good communication across the teams. Set guidance so all staff are aware of the process. Increased monitoring support for all clients Response: Staff experience of MAT standards of staff rated their current knowledge and understanding of the MAT standards as "excellent" or "very good" of staff felt supported to gain the knowledge, skills and confidence to implement the standards. 100% 100% positive feedback was received from clients on the new MAT model MAT is a vast improvement with regards to waiting times to be seen and receive prescribed medication. I have only received positive feedback from prescriber and client on this new MAT model. Response: Question: What is required in order for the MAT standards to be rolled out as a sustainable and consistent model? Question: Please state any further comments/suggested improvements you would like to make on the delivery of the MAT standards so far? Feedback received from other clients across North Ayrshire is that they would be prepared to travel to Caley Court if they could receive same day MAT intervention, however other clients would prefer to be seen in their own locality areas. Response: Feedback was received from a small staff group, who were more specifically involved in the MAT Test of Change. Next steps - There is currently an implementation plan in place to ensure full MAT delivery is extended across North Ayrshire by the end of the summer.
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This table provides the detail of RAG status for each of MAT standards 1-5 for each ADP area.
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Appendix 6: NHS Ayrshire & Arran, North Ayrshire ADP area Evidence-based assessment of progress, MAT standards 1–5. April 2022 Overview of MAT service provision The North Ayrshire Drug and Alcohol Recovery Service have developed pathways of support so that there will be no barriers to accessing treatment and care that supports an individual’s recovery. The focus is on improved access to appropriate MAT in order to prevent deaths, reduce harms and promote recovery opportunities. Harm-reduction interventions will be delivered alongside physical and mental, health- related support to enable individuals to remain in treatment for as long as required. Accompanying psychological and social support will be available to all individuals. An improvement/action plan has been identified and agreed with the MIST and this will be supported via the local North Ayrshire Drug and Alcohol Recovery Service Clinical and Care Governance Group, a local multi-agency Oversight Group and a pan-Ayrshire MAT Steering Group to ensure consistency of MAT delivery across Ayrshire and Arran. The work of lived experience interviews and recommendations will also form part of the local and pan-Ayrshire improvements MAT standard 1 is partially implemented (amber) There is process evidence to demonstrate a current test of change and an ongoing service that enables people to receive a prescription for opioid substitution therapy on the day of first presentation. This is currently being scaled up to be five days a week but is not yet available in justice settings. There is a pan-Ayrshire and Arran standard operating procedure that offers guidance and consistency across the three council areas. This document outlines referral processes including the option of
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same day prescribing, choice of opioid substitution therapy, care plan review processes, pathways to identify people at risk of drug harm, pathways for harm reduction and recognition that the recovery care package should differ depending on the individual's needs and requirements. Numerical data from October to December 2021 indicate: • 50% (n=16) of people were prescribed on the day of referral • 25% (n=8) of people waited two days or less. Numerical data taken from the pilot between January to March 2022 indicate: • 83% (n=15) of people where prescribed on the same day. These figures most likely represent only a portion of a person's journey from first presentation to the multi-agency team to a prescription. Clinical audit of a documented pathway is required. Experiential evidence provided following the pilot to improve services in North Ayrshire reported that the 32 people who commenced medication assisted treatment on same day, or the next day after assessment, received a mental health assessment and support as required, and had the opportunity of family involvement. All people had the opportunity to access recovery development workers with lived experience to provide person centred recovery support. This standard is partially implemented (amber) because at this time, evidence does not indicate consistent access across the ADP. While data imply that to rapid access is available, this is only the data from the pilot. There are documented plans in place to scale up and offer same day prescribing across the geographical area, that will progress to full implementation of the standard. MAT standard 2 is fully implemented (green) Process evidence indicates that clinical guidelines include methadone, short, and long-acting buprenorphine as treatment choices for people who present to services. These are also available in local formularies. A Home Office licence is in place to
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allow for the storage and supply of opioid substitution therapies from the Caley Court Resource Centre There is pan-Ayrshire standard operating procedure for named patient prescribing for long-acting injectable buprenorphine medication to offer choice across a wider geographical area. For people accessing services, information leaflets are available to inform and support the choice of opioid substitution therapy. Numerical evidence provided from October to December 2021 indicates that the proportion of people prescribed specific medication was as follows: • methadone 87% (n= 714) • oral buprenorphine 12% (n=97) • long-acting injectable buprenorphine 1% (n=8). January to March 2022 the figures remained stable. The ADP reports the uptake for long-acting buprenorphine has been slow but is a treatment choice for all people across the ADP area. This standard is fully implemented (green) as all process documentation is in place to allow people across the ADP area to have a choice of MAT. MAT standard 3 is fully implemented (green) There is a pan-Ayrshire Near-fatal Overdose Emergency Response Pathway outlining the approach to safely respond to people experiencing near-fatal overdoses who have been identified by the Scottish Ambulance Service. The MAT standard operating procedure guides staff to conduct a formal risk assessment to identify people who are particularly vulnerable when accessing the service. This includes, but is not limited to, people identified at higher risk, and people leaving prison. A more detailed Prison Addiction Service standard operating procedure also supports this and further work is in progress to ensure MAT Standards are embedded in these settings by 2022.
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Information sharing agreements are in place between NHS Ayrshire and Arran, Scottish Ambulance Service, Police Scotland, Scottish Fire and Rescue Service, and the Health and Social Care Partnership. Guidance is available for staff to support individuals experiencing co-existing mental health, alcohol and/or drug use. This includes notification and referral processes to alert services if an immediate response is required. Adult and child protection procedures are in place. Numerical data from January to March 2022 indicate that there were 46 notified incidents reported with all people receiving an initial assessment on the same day. From October to December 2021, five incidents were notified and the median wait was four days. All people received a joint community and substance use intervention. The ADP has documented plans to build upon the existing ‘Duty Triage Team’ to create a wider North Ayrshire drug and alcohol recovery service response team offering same day MAT assessments and prescribing (minimum of five days a week). It will respond to near-fatal overdose, offer administration of long-acting injectable buprenorphine, regular review appointments, support for individuals released from prison and same day care for people in the Housing First programme. This standard is fully implemented (green) because a documented system is in place and there is good evidence that people receive an appropriate and timely response. This model will be useful nationally. MAT standard 4 is fully implemented (green) A MAT standard operating procedure defines a process for the delivery of harm- reduction interventions for all staff across NHS Ayrshire and Arran. It states that all staff are trained in overdose awareness and prevention and have access to naloxone for personal-carry and onward supply. A harm-reduction checklist guides and supports staff to discuss the three evidence-based harm-reduction interventions (injecting equipment provision, take-home naloxone and blood-borne virus testing).
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Experiential evidence from the North Ayrshire Pilot indicates that all individuals in the pilot were offered blood-borne virus testing, naloxone, injecting equipment, physical health assessment including sexual health, and other harm-reduction interventions. This standard is fully implemented (green) because the core harm-reduction interventions, injection equipment provision, take-home naloxone and blood-borne virus testing are reported to be available at the same time and place as all MAT appointments in all community settings. This is evidenced by documentation. Justice settings present a challenge and there needs to be a commitment to offer the full range of harm-reduction interventions in all sites. MAT standard 5 is fully implemented (green) The ADP reports a variety of approaches to enable retention in care and safe discharge. There is a pan-Ayrshire Promotion Engagement in Addiction Services standard operating procedure that is currently being reviewed and updated to reflect MAT standard 5 and it recognises that the recovery care package should be specific to the individual's needs and requirements. There is no option to prescribe opioid substitute treatment in primary care services. Multi-disciplinary teams use collaborative processes to support individuals accessing services. In turn, people are supported to access primary care services such as GPs, community pharmacies, opticians and dentists. Family or nominated persons are also encouraged to attend to support retention of the service. Numerical data provided indicate that: • as of March 2022, 50% (n=457) of people had been on MAT for 1,839 days or more (five years) • between October to December 2021, of 67 planned discharges 50% (n=34) were on MAT for 210 days or more 75% (n=50) for 55 days or more • between October to December 2021, there were no unplanned discharges from MAT
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• between January 2022 to March 2022, the median time on MAT for unplanned discharges was over 1,700 days and 75% (n=6) had received MAT for 16 months or more. This standard is fully implemented (green) as systems are in place to enable people to stay in a treatment of their choice, for as long as they need. The service continues to explore multiple forms of caseload management, including a tiered recovery orientated model of care based on peoples own choice. The only limitation is no shared care with primary care, however, pathways are in place to support engagement with primary care. There is a process in place under standard 3 to follow up people who disengage from treatment. Learning from this model could be useful nationally. Progress with implementation of other projects The implementation of MAT standards is not a stand-alone development and is incorporated into other identified workstreams and projects, which include, but is not limited to the following: • Adherence to the new ‘Substance Use Treatment Target’. • New responses and pathway of support for individuals following a near-fatal overdose. • Improving the multi-agency pathways of support for individuals with a ‘Dual Diagnosis’. • Identification of pathways to support individuals to access residential rehabilitation support. • Enhanced support via the Housing First programme incorporating dedicated alcohol and drug and mental health support. • Dedicated advocacy worker.
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Improvement plan to implement the MAT standards by April 2023 The detailed action plan, Gantt chart and method for evaluation of change will be developed by the ADP and MIST. A programme management approach will be taken to complete the actions below. This will require committed resources to ensure delivery. The ADP coordinator will sign off the programme. 1. Implement further test of change for MAT standards 2, 3 and 8 in justice settings across Ayrshire and Arran and share learning • Timeframe: o Commence in August 2022 and report on the first quality improvement cycle in December 2022, demonstrate partial or full implementation by April 2023. • Actions: o Conduct mapping of the MAT standards in Ayrshire and Arran justice settings and initiate systems to implement MAT standards across the local pathways that link prison, police custody and the community. o Ensure sufficient process, numerical and experiential evidence to demonstrate progress. 2. Scale up the MAT standards 1–10 in the community • Timeframe: o Commence in August 2022 and demonstrate full implementation of standards 1–5 and at least partial implement of standard 6–10 by April 2023. • Actions:
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o Collaborate with national thematic groups. o Establish scale-up plans for all standards. Specific components for scale up include: ▪ Scale up the provision of accessible community based same day prescribing across the whole of North Ayrshire (MAT standard 1). ▪ Scale up the provision of long-acting injectable buprenorphine to all clients receiving MAT who wish it (MAT standard 2). ▪ Continue to develop models to retain people in services for as long as they request by continued support of models of care creating further capacity and share the learning nationally (MAT standard 5). ▪ Provide structured psychological interventions (Tier 2) to address mild to moderate comorbid mental health issues and to support people's recovery from substance use. Enhance support and training for psychologically informed treatment and trauma-informed care (MAT standards 6 and 10). ▪ Continue to explore models of shared care with primary care (MAT standard 7). ▪ Increase rights based advocacy support to people in treatment by commissioning dedicated advocacy input (MAT standard 8). ▪ Continue to improve access to recovery groups and peer support. ▪ Continue to support access to family and carer support. 4. Assistance provided by the MAT Implementation Support Team • Assist implementation of tests of change with examples and templates of quality improvement charters, operating procedures, approaches to numerical and experiential data collection (e.g. data sets, collection and analysis tools), project cycle review, reporting and plans for scale up.
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• The establishment of thematic ADP clusters that will enable benchmarking, information sharing, spread of good practice, development and dissemination of tools (e.g. audits, template documents) and inter-organisational support. • Implementation of a programme management approach to ensure systematic implementation. • Updates of standard operating procedures, guidelines and plans in line with the recommendations in the MAT standards and that address the gaps identified through a review of the evidence provided. • Capacity building and systems to collect numerical and experiential evidence to demonstrate progress and use as part of the improvement cycles.
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Annex 1: Process evidence submitted MAT standard Title Description 3 Ayrshire and Arran information sharing protocol Information Sharing Protocol 1 Benzodiazepine Prescribing Guideline Prescribing Guidelines 1 Buprenorphine Oral Lyophilisate Prescribing within NHS Ayrshire and Arran Community Addictions Services Prescribing Guidelines 1 & 2 Buvidal® (Buprenorphine Depot) for Opioid Substitution Treatment Prescribing Guidelines 1 Care planning presentation and training Prescribing Guidelines 3 Child Protection Wellbeing Concerns Guideline (MHS) Wellbeing Guidelines 2 Choosing the right treatment for opioid dependence leaflet Leaflet 4 Community Health Addiction Nurse Job Description 3 G120 – Adult Support and Protection Policy 1 General principles of prescribing practice within NHS Ayrshire and Arran addiction services Prescribing Guidelines 3 Guidance for NADARS staff requiring Mental Health support Guidance and flowchart
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MAT standard Title Description 3 Guidance individuals with co-existing mental health and alcohol and or drug issues Guidance document 3 & 4 Harm-Reduction Interventions with MAT – Checklist Checklist 5 Implementing medication assisted treatment (MAT) – client experience Project poster + Improvement plans 1 Index - material under development Index 1 MAT standards – planned audit template Audit 1 Medication Assisted Treatment (MAT) Standard Operating Procedure Standard Operating Procedure 3 NADARS – RAG Recording (May 2021) RAG recording guidance 1 NADARS and Ward 5 – Service user satisfaction Audit feedback 3 NADARS RAG status RAG Status 1 NHS Ayrshire and Arran complaints handling procedure Procedure (complaints) 3 Pan Ayrshire agreement non-fatal overdose – referral pathways and processes Procedure (NFOD) 5 Promoting Engagement within Community Addiction Services Standard Operating Procedure
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MAT standard Title Description Standard Operating Procedure 1 Record keeping for mental health and learning disability nurses and non- registered professionals' guideline Record keeping standards 1 Suboxone flow chart Flowchart 1 Supervision for Mental Health, Learning Disability nurses and non-registered Professionals Guidance Supervision guidance 1 The Ayrshire mental health conversation Strategic Plan 3 The Scottish Ambulance Service (SAS) and the North Ayrshire Drug and Alcohol Recovery Service (NADARS) non- fatal overdose response and support pathway Service and referral pathway Annex 2: Summary of numerical evidence provided MAT standard 1 Data source: Local database Method, caveats and learning: Reports on individuals referred within the MAT pilot area. Results:
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Chart 1: Days from first contact to initiation of MAT in the MAT pilot area Chart commentary: From October to December 2021, 31 people started MAT in the MAT pilot area. From January to March 2022, 18 people started MAT. 50% (n=16) of people were prescribed on the same day as referral with a further 25% (n=8) of people waiting two days or less from referral to prescribing in October to December 2021. This number was reduced to zero days for 83% people (n=15) for the months January to March 2022. The longest wait was 18 days in October to December 2021, with the maximum waiting time in January to March 2022 being reduced to seven days. MAT standard 2 Data source: Local database Methods, caveats and learning: People receiving a prescription including MAT Pilot area. Results:
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Chart 2: Number of people prescribed specific opioid substitution therapy medications, October 2021 to March 2022. Chart commentary: From October to December 2021, the proportion of people prescribed methadone was 87% (n= 714), oral buprenorphine accounted for 12% (n=97) and injectable buprenorphine 1% (n=8). The total number of people prescribed opioid substitution therapy was 819. In the period January to March 2022, the proportion of people prescribed methadone decreased slightly to 86% (n= 703) while the proportion of oral buprenorphine and injectable buprenorphine remained the same. Comparing October to December 2021, the total number of people prescribed opioid substitution therapy was 819, with this reducing to 814 over January to March 2022. MAT standard 3 Data source: Local database Method, caveats and learning: Individuals referred through Near-Fatal Overdose Pathway out with MAT Pilot area. The numbers for October to December 2021 are low as recording started during that time. Numbers include existing people as well as those newly identified.
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Results: From January to March 2022, all 46 notified high-risk incidents are reported to have received an initial assessment on the same day. This is a reduction in time when compared to October to December 2021, where fewer than five high-risk incidents were notified and the median number of days wait was four, the longest wait was seven days. All people assessed received a joint community and substance use intervention. MAT standard 4 Data source: Local database Method, caveats and learning: None stated. Results: There is one location offering all three core harm reductions, take-home naloxone and overdose, injecting equipment, and blood-borne virus testing, at initial and subsequent appointments. This location also offers assessment of injecting risk, wound assessment and sexual health counselling. MAT standard 5 Data source: Local database Method, caveats and learning: Individuals (including MAT Pilot area) who have received a prescription during this reporting period and those who are no longer receiving a prescription but still receiving support. Following analysis of the data for planned and unplanned discharges at service level (see chart 4 and 5 below), a range of explanations can be given to account for the median being reduced. Individuals accessing MAT may decide that, following assessment and prescribing, that this is not the time for them to begin MAT. The North Ayrshire ADP will work with North Ayrshire Drug and Alcohol Recovery Service to further understand how to record this or what can be done to track individual's re-entry to the service. The service is currently very proactive in following up, but these numbers may also include those referred but never attended, and some individuals who appear to have
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moved address. There will be an ongoing element of these data that includes those who may be placed on remand or have longer prison sentences. These numbers will continually fluctuate (and are evident in previous data) depending on patient choice, individuals' demographics and other social factors that will continue to affect retention in treatment and discharge figures. The understanding behind these circumstances and choices made can continue to be explored further to inform service delivery. Results: • Part 1: Current MAT caseload. Refer to chart 3 below. • Part 2: Planned discharges. Refer to chart 4 below. • Part 3: Unplanned discharges. Refer to chart 5 below. Chart 3: Number of people on the current caseload, December 2021 and March 2022 Chart commentary: As at 31 December 2021, the number people on MAT on the caseload was 830. This increased to 914 at the end of March 2022. Time currently
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on MAT ranged from 0 days to 4,434 (over 12 years) as at 31 December 2021, compared to 0 days to 4,524 (over 12 years) by the end of March 2022. 50% (n=415) of people had been on MAT for 1,897 days (over five years) or more as at 31 December 2021 compared to 31 March 2022 where 50% (n=457) of people had been on MAT for 1,839 days (around five years) or more. 75% (n=623) currently remained on MAT for 643 days (around 18 months) or more as at 31 December 2021 compared to 75% (n=686) remaining on MAT for 594 days (around 19 months) or more at 31 March 2022. Chart 4: Number of days retained on MAT for planned discharges, December 2021 to March 2022 Chart commentary: For the quarter ending 31s December 2021, there were 67 planned discharges from MAT. The minimum length of time on MAT was three days and the maximum 4,249 days. 50% (n=34) of people discharged were on MAT for 210 days or more with 75% (n=50) of service users on MAT for 55 days or more. The minimum and maximum number of days retained on MAT for planned discharges is similar for the months of January 2022 to March 2022, however, the median number of days decreased by 50%.
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Chart 5: Number of days retained on MAT for unplanned discharges, January to March 2022 Chart commentary: Between October and 31 December 2021 there were no unplanned discharges from MAT. From January 2022 to March 2022, the median time on MAT for unplanned discharges was over 1,700 days (approximately four and a half years) and 75% (n=6) had received MAT for at least 470 days (approximately 16 months). Annex 3: Summary of experiential evidence provided Data source Method and participants Comments Implementing MAT – Pilot Report, North Ayrshire Drug and Alcohol Recovery Service (NADARS) Evaluation of pilot of implementation of medication assisted treatment (MAT). Evaluation of outcomes of pilot only (April–September 2021) so no data regarding the longevity of support/ treatment or ‘moving on’. NADARS and Ward 5 – Service user satisfaction audit programme (2022) Audit programme 2022: plan for collecting service user satisfaction. Programme only – includes plan to collect feedback from people accessing medication assisted treatment.
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Scottish Ministers, special advisers and the Permanent Secretary are covered by the terms of the Lobbying (Scotland) Act 2016. See www.lobbying.scot St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.gov.scot Minister for Drugs Policy Angela Constance MSP T: 0300 244 4000 E: scottish.ministers@gov.scot Integration Authority Chief Officers Territorial Health Board Chief Executives Local Authority Chief Executives Copied to: Chairs of Territorial Health Boards and Integration Joint Boards COSLA SOLACE Alcohol and Drug Partnership Chairs ADP leads «Address7» ___ 23 June 2022 I am writing this letter of direction to all Territorial (Local) Health Boards, Integration Authorities and local authorities, using authority from section 52 of the Public Bodies (Joint Working) (Scotland) Act 2014 in relation to the carrying out of functions conferred by that Act, delegated in pursuance of an integration scheme or to be specifically carried out in conjunction with those, and which require specific responses to achieve implementation of the Medication Assisted Treatment (MAT) standards published on 31 May 2021. The MAT standards are one of the platforms for successful delivery of the National Mission to save and improve lives in response to Scotland’s drug deaths crisis. The standards enshrine a rights-based approach to immediate, person-centred treatment for problem drug use, linked to primary care, mental health and other support services. Although the standards were published on 31 May 2021, these had been well publicised and local areas had contributed to their development through the Drug Deaths Taskforce. Both the First Minister and I announced that these standards needed to be embedded and implemented by April 2022 and the Scottish Government is providing funding to help local services deliver on embedding, improving and sustaining the MAT standards. We have also established an implementation support team (MIST) including practitioners and people with lived experience, and led by Public Health Scotland to support local areas scale up and implement the standards. In 2021/22 we provided £6 million for MAT implementation along with £3 million for assertive outreach and £3 million for non-fatal overdose pathways (both of those initiatives contribute to MAT standard 3) as well as £4 million to support local areas for the use of long acting buprenorphine (MAT standard 2). We also provided £500,000 last year (and committed to the same per year for the life of the Mission) for local areas to set up and run local forums or panels to feed in views from people with lived and living experience to MAT implementation as well as to other aspects of service delivery. I have also announced that funding for the remaining years of the National Mission – to April 2026) has been increased from £6 million to £10 million per year.
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Scottish Ministers, special advisers and the Permanent Secretary are covered by the terms of the Lobbying (Scotland) Act 2016. See www.lobbying.scot St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.gov.scot Today, Public Health Scotland is publishing a MAT Implementation Benchmarking Report which shows that while progress on implementation has been made in all areas, and MAT standards 1 – 5 have been implemented fully in Borders, the standards had not been implemented fully by April 2022. In response to this Report and in order to achieve full implementation, Ministers will expect the following actions to be taken and oversight arrangements in place in each local area: a) That, by the end of September, Chief Officers and Chief Executives personally sign timed, specific and published Improvement Plans for implementing the standards – to include the delivery recommendations being made locally with MIST which are to be published by PHS on 2 August; b) The Improvement Plans and the reporting on progress must involve and include the voices of those with lived and living experience. It will be for each local area to determine what arrangements it needs to have in place to ensure this is done, potentially drawing on MIST lived experience support, from third sector partners or from their own local forums or panels; c) That Chief Officers and Chief Executives take shared and visible responsibility for delivering the standards (with the Chief Officer being responsible for overall delivery and the Chief Executives committing to support them). This requirement should align with on-going work to define and refine local governance and accountability over alcohol and drug services; d) That Chief Officers and Chief Executives include reports on progress as part of the regular Board quarterly reporting against Annual Delivery Plans (the first report in this series is due in July 2022); e) Health Boards, Integration Authorities and local authorities are to identify a senior leader for each Integration Authority area as the single point of operational responsibility for driving the changes necessary; f) Should any quarterly report identify the need for intervention, that this is acted on immediately. Further, I will follow up directly with any additional asks of Health Board or Integration Authority areas where the proportion of drug deaths remains significantly high and where MAT standard 1 is not yet implemented, and for those areas, we will require monthly progress reports rather than quarterly. Our expectation is that, these oversight arrangements will lead to implementation of the MAT standards in community and justice settings in all local areas, in accordance with the timetable for full implementation being recommended in the PHS Benchmarking Report, at the very latest. The Scottish Government and the MIST team, in particular, will continue to provide advice and support to all local areas to set up the above arrangements and to achieve the intended goals. Addressing this requires a whole-system approach across Government and across local services.
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Scottish Ministers, special advisers and the Permanent Secretary are covered by the terms of the Lobbying (Scotland) Act 2016. See www.lobbying.scot St Andrew’s House, Regent Road, Edinburgh EH1 3DG www.gov.scot The requirements set out in this letter of direction will subsequently be revoked when implementation has been achieved locally, and notice of that will be in a further letter. I thank you, and those who are charged with delivering support and care in accordance with the MAT standards, for your on-going commitment. Ministers recognise that there are huge efforts being made already to deliver on the standards and to provide the necessary care for some of the most marginalised people in our communities, to save and improve lives. This letter is intended to ensure that the work being done on the ground is backed up more consistently through commitment from senior leaders. ANGELA CONSTANCE