Transcript Annette Dale-Perera

NHS Addiction Services
Outcomes
Annette Dale-Perera
Strategic Director of Addiction and Offender Care
Effective treatment, changing lives
NHS provider land
NHS Foundation Trusts
BIG FISH EAT LITTLE FISH
Financial efficiency savings required (20% over 4
years)
Implementing service line management & getting ready
for Payment by Results (PbR) : Outcomes
CNWL PDU population 2009: aging and ill
population
4,077 PDUs in community drug treatment
Age: Mean 36, almost half (48%) 40+: almost a third (31%) over 45
BBV
58% of IDUs have Hep C;
At least 25% HCV + get chronic liver
disease 20 - 30yrs after infection:
NOW
15% Hep B; 4% HIV
Severe mental health problem:
27% severe depression;
8% psychosis; 37% Personality Disorder.
Smoking: almost all
Socio-demographics:

24% NFA or housing problem

79% unemployed at intake
People with severe mental illness
die15 -20 yrs early
Heavy smoking reduces life by
average of 8.8 yrs
Only 15% previous regular
employment EVER
 A third (34%) to 40% have severe physical health plus severe mental
health issues plus long term unemployment and are over 40
CNWL Outcome results: at TOP review
CNWL addiction services had a positive impact on SM
 73% of opioid only users were abstinent or reliably improved
Of opioid plus crack users
– 53% were abstinent or had reliability improved their opioid use
– 60% were abstinent or had reliably improved their crack use.
 Injecting behaviour also reliably improved in almost 80% of injectors.
 CNWL addiction services performs better than national data NTA data
(cited in the Lancet 2009) on changes in illegal opioid use amongst
opioid (not crack) users at treatment review and slightly less well (34%) with opioid plus crack users.
CNWL Outcomes substance use at review
a) Opioid users (no crack) change in illegal opioid use at review Note: 13 days diff in opioid use required for `reliable change’
mean days at
start
Mean days at
review
7679
23
9
13.6
71
42
29
26
2
892
23
7
17
73
44
29
26
1
n
NTA National
data
All CNWL
Mean
Days Diff
% positive
%
Abstinent
% reliably
improved
%
unchanged
%
deteriorated
b) Opioid & crack users change in illegal opioid use at review. Note 13 days diff in opioid, 12 days in crack use for `reliable change’
mean days
at start
n
Opioid use NTA data
5863
23
Mean days at
review
7
Mean Days
Diff
15.7
% positive
change
% Abstinent
65
33
% reliably
improved
% unchanged
32
32
%
deteriorated
3
3
Opioid use CNWL
Crack use NTA data
796
22
9
13
64
29
35
33
7114
13
5
7.7
64
51
13
33
3
3
Crack use CNWL
796
12
5
7
61
48
13
36
CNWL Outcomes substance use at review
c) Primary alcohol users change in alcohol use at review Note: 10 days difference in alcohol use required for
`reliable change’
mean days at
start
N
All
CNWL
889
24
Mean
days at
review
15
Mean
Days
Diff
%
positive
change
9
44
%
Abstinent
25
% reliably
improved
19
%
unchanged
%
deteriorat
ed
53
4
Alcohol users, 43% were abstinent or reliably improved at review.
Health, social functioning and crime
outcomes at review
 CNWL drug treatment had significantly reduced crime in more than
80% of cases (both reducing shoplifting and selling drugs).
 3% were in education at treatment start – less at review.
 Around a quarter were working prior to treatment. There was no change
in mean days employed at review
– 3-5% in the number of drug users working more than 10 days
– and a 1% fall in alcohol users working more than 10 days)
 13% heroin users, 21% heroin & crack users, 11% alcohol users had
housing problems at start: some improvement (3-6%fall) at review
 Health and quality of life ratings increased slightly (by 1 or 2 out of 20)
at review but not generally to a level of reliable change.
Substance misuse outcomes at exit
 CNWL services had a positive impact on substance misuse by exit:
 90% of opioid only users were abstinent at exit and 6% were reliably
improved thus 96% had achieved positive change.
 Of opioid plus crack users
– 83% were abstinent and 9% had reliably improved their opioid use
– and in terms of crack use 83% were abstinent and 6% had reliably
improved.
 Injecting behaviour had also stopped n 94% of injectors.
 There were however, a small minority of clients did not reliably change
as a result of treatment.
CNWL drug use outcomes at exit
a) Opioid users (no crack) change in illegal opioid use at exit Note: 13 days diff in opioid use required for `reliable
change’
n
All CNWL
mean days
at start
185
24
Mean
Days
Diff
Mean days
at exit
1
%
positive
23
%
Abstinent
96
90
% reliably
improved
%
unchanged
6
%
deteriorated
3
0
b) Opioid & crack users change in illegal opioid use at exit Note: 13 days diff in opioid use, 12 in crack required for reliable
change
mean
days at
start
n
All CNWL
Opioid use
All CNWL
Crack use
Mean days
at exit
Mean
Days
Diff
% positive
change
%
Abstinent
% reliably
improved
%
unchanged
%
deteriorated
23
2
21
92
83
9
8
0
12
2
10
89
83
6
10
1
All 144
CNWL alcohol use outcomes at exit
Primary alcohol users change in alcohol use at exit Note: 10 days difference in alcohol use required for
`reliable change’
mean
days at
start
n
All CNWL
904
23
Mean days
at exit
6
Mean
Days Diff
17
%
positive
Change
76
%
Abstinent
59
% reliably
improved
17
%
unchanged
%
deteriorated
22
1
Of CNWL primary alcohol users, 76% had positively changed and were abstinent
or reliably improved.
Health, social functioning and crime
outcomes at TOP review: key points
 CNWL drug treatment had significantly reduced crime in more than 94%
of cases (both reducing shoplifting and selling drugs).
 Although there was an increase in the number of drug users working at exit
BUT rates of employment were low, 24% heroin users, 21% heroin and
crack users, 19% alcohol users.
 All groups were less likely to be in education.
 Less people with housing problems at exit (1-2% alcohol and heroin
users but 8-10% heroin & crack users)
 Health and quality of life rating increased slightly on ratings at review but
not to a level of reliable change. Around a third of clients had significantly
improved ratings, sixth of clients reported feeling worse and half had
ratings that were unchanged compared to start.
Conclusions
 Yes: commission me on my outcomes
BUT
 I do well to keep some alive – I have 50 deaths a year
 35-40% of my services users who are drug users are over
40, have never worked, have multiple substance misuse,
mental health issues and have Hep C
 We can increase quality of life, health and well-being and
reduce crime…….but employment ??????
 Overly complex PbR is at worst likely to fail. No evidence it
works for employment……………..
 Beware of `gaming’