Standard 1.All people accessing services have the option to start MAT from the same day of presentation.
Putting the Person at the Centre of Service Delivery
I am a substance use nurse specialist and have been a practicing nurse prescriber for over a decade and was awarded the Queens Nursing Title in 2018 for delivering compassionate care with humility. I am currently on secondment to the Scottish Government for the Scottish Drugs Task Force to support the consultation and implementation of Medically Assisted Treatment (MAT) Standards, across Scotland. The MAT Standards are based on a human rights approach delivering services for those using drugs, with the person being at the centre of the decision making, around their treatment.
The cornerstone of my approach was to gain a better understanding of the trauma experienced by people who use drugs as I believe that the foundation to understanding the adversities experienced by those who use drugs, lies at the heart of identifying the best way forward for treatment. Seeing and actively listening to each person is essential if we are to truly identify the deeper needs of an individual, placing them firmly at the centre of all decisions concerning their treatment and care planning.
There is clear evidence that, drug-related deaths are increasing and in 2018, one or more opiates were implicated in, or potentially contributed to 86% of all deaths, as outlined in national trends. There is strong evidence that the health of those with opioid dependence is safeguarded, whilst in treatment however, it is estimated that there is as little as 42% of those who use opioids in treatment services across Scotland. I identified the need for change within the services I managed in Midlothian and sought out ways to meet the appropriate needs of those who needed or wanted to access treatment. Many of the people using drugs will have had lived through previous hardships, suffering and trauma, which can have an impact on their coping mechanisms, vulnerability and their ability to establish trusting relationships with professionals. Barriers to treatment need to be reduced to build mutual trust such as; lengthy and potentially traumatic assessment processes, tackling stigma and the fear of being judged by service providers/communities, which is sadly often a reality, as well as the need to be guided by people with lived/living experience of using drugs to support the development and delivery of services.
In summer 2018, I developed a “low threshold” drop in clinic/cafe model in Midlothian. The café clinic’s had a deliberate focus on targeting those we had failed to reach, as without support, they had a higher risk of drug related harm and death. The cafe clinic aimed to break down any previous barriers people might have experienced and is run alongside our recovery cafe, Horizions. It offers individual, holistic support to meet a variety of health and wellbeing needs, including access to blood Bourne virus testing, needle exchange, sexual health, and opiate substitute prescribing (OST), peer volunteers, employability and food. The approach is person centred and is based on a Good Conversations model of delivery “what matters to you“ with the focus on establishing any underlying issues and/or social difficulties, as opposed to simply knowing what substances people are using. This model was successful in increasing attendance from under 30% to more than 90 %. The learning from this pilot/project was the abiity of being able to meet the needs of those attending, who used the needle exchange and being able to offer rapid access to OST.
Our traditional model for initiating OST would be a client attending a Gateway Clinic (self-referral drop in) and being appointed to a nurse within 21 days for assessment for treatment. The assessment process would be usually over two appointments whereby a full social, housing, mental health, history would be taken, including access to any children and criminality. Feedback from those using services found this to be a barrier to accessing treatment as they felt that had to “jump through these hoops” to access OST. To increase easier and quicker access to OST, I decided to undertake a test of change using QI methodology based on the Middlesbrough model, which had been practicing initiating OST prescribing on the day of presentation at the service. This reduced the length of time for the assessment process, to one that focused on the presenting issues for the person who wanted to start on OST. This was not based on a medical model but one of choice for those using the services – the choice of medication and dosage, and with them being at the centre of the decision making around the care planning. The person could make an informed choice on whether they wanted a structured one to one key working with a named nurse or attending a drop in cafe clinic, if this was preferable. Peer support volunteers were also available to advise on other recovery supports in the local community or to offer 1:1 support.
Over a 12-month period, this QI project, started with a sample of 15 people, all of who are still in service (only one moving out of area). Five people are in residential rehabilitation, 2 have been referred on for trauma work, 1 is in full time employment, and the others remain fully engaged, with positive individual outcomes. 70% of people who were involved in this pilot had previously experienced a Near Fatal Overdose prior to starting on OST with only one having a further near fatal overdose. The team in Midlothian saw a 60% increase in referrals to OST from the same time the year before – so this gives us some evidence that offering low barrier access to MAT needs to happen so we can meet the needs of those using our services.
We need to be inspirational in our service delivery plans incorporating all the 10 Medication Assisted Treatment standards, learning from each other and those who use or have used services. A priority in Scotland is reaching out to people who require MAT and to offer a service they can connect with, that meets the needs of them and their families, and one which they value.