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- pathways to specialist treatment
- Increasing the percentage of patients who were offered treatment and vaccination.
- Reducing the percentage of patients who refused the offer of BBV testing or immunisation.
- Increasing the percentage of patients who had a test or were vaccinated.
- Improving pathways between substance misuse treatment and tertiary services for the treatment of hepatitis or HIV.
- Evidence-based care bundles provide standardisation of good practice and improved data.
- There is no single solution or blue-print model for the improvement of BBV interventions in substance misuse services. Solutions must found at local level instead.
- There is a number of generalisable and common factors for success and improvement, which have to be in place to drive improvements. These revolve around:
- System redesign
- Human resource development
- Culture change
- QI must adapt to the changing context of the NHS and funding for substance misuse treatment.
The PREVENT (PREvention of blood-borne Viruses through Education, clinical Networks, Testing and Treatment in substance-misusing populations) project has been designed to prevent patients using our substance misuse treatment services from contracting blood-borne viruses (BBV).
It does this through early screening and testing for BBVs, as well as education and vaccination. It also focuses on improving the referral and engagement of patients who test positive for BBV in tertiary hepatology and HIV treatment.
People with substance misuse disorders are a marginalised and often vulnerable group. They are at particular risk of morbidity and mortality from BBVs and preventable infections, specifically hepatitis B (HBV), HIV and hepatitis C (HCV). In particular, hepatitis C is a major health concern for this group, especially for those who inject. Current estimates suggest that around 216,000 individuals are chronically infected with hepatitis C in the UK, and of these 90% acquired it through injecting. In London, the prevalence of BBVs is high, with approximately 64% of injectors in the capital believed to be hepatitis C positive.
Each year, approximately 6,000 patients receive substance misuse treatment from the 15 clinical services provided by CNWL’s Addiction and Offender Care Directorate (AOCD) in eight London boroughs. PREVENT started its work in May 2010 to make improvements in BBV testing, hepatitis B immunisation and referral of patients to tertiary treatment across AOCD services and increase the percentage of patients receiving these interventions in a timely and reliable way. At the time, although patients were tested and vaccinated for hepatitis B and referred to tertiary services, many were not receiving these interventions.
PREVENT worked in partnership with addiction services, using Quality Improvement (QI) tools and methods. Together, they were successful at making improvements at local levels. A number of lessons were also learnt and are applicable to BBV interventions in drug treatment services across the UK.
The PREVENT project is implemented in three stages:
The outcomes of the project are as follows:
GAP 1: Offer of BBV screening for all patients
PREVENT aim: 100%
Current national performance: 40-60%
Additional aims: Reduce refusal of test by 50%; increase ‘test taken’ by 50%
GAP 2: Offer of hepatitis B vaccination for all patients
PREVENT aim: 100%
Current national performance: 60% offered but only 53% completed course
Additional aims: Reduce refusal of immunisation by 50%; increase ‘test taken’ by 50%
GAP 3: Appropriate referral to specialist services
PREVENT aim: 100%
Current national performance: No data
Additional aims: Increase referral by 50%
Quality Improvement framework
PREVENT is a Quality Improvement (QI) project, based on the Institute of Health Improvement’s framework.
Service user input
PREVENT’s work was informed by service users’ views of the obstacles and solutions to improvement. At the onset of the project, we held nine focus group discussions with 50 service users to inform the changes needed for improvements to be made in BBV-related interventions.
QI methods and tools
We have used a number of QI tools to drive system changes at Trust-wide (macro) level (and beyond) and local clinical (micro) level. At Trust-wide level: we developed care bundles for testing for BBVs, for BBV immunisation and for referral to tertiary services. We have disseminated these across AOCD services to ensure the standardisation of good practice and improved data collection. At local clinical level: local substance misuse services implemented these care bundles. System changes were made and tested through Plan, Study, Do, Act (PDSA).
Other resource development
We also provided additional support, such as standardised training and guidance, service mapping and referral templates.
Data and project results
We collected both quantitative and qualitative data. Analysis showed that PREVENT has been successful in making improvements at macro and micro levels. The project also showed what works and identified barriers to improvement. In particular, it supported improvement by:
PREVENT was successful in meeting its objectives despite a challenging new external environment, that coincided with the start of the project. These included economic recession, a reduction in resources, and service restructure, including abolition of BBV specialist posts in drug treatment services within the Trust.
The PREVENT project enabled the following learning:
At Trust-wide level:
At local clinical level: