About this webinar
The seminar introduced participants to the aims and methods of this multi-phase study. It focused on the findings of a meta-synthesis which involved analysis of 63 unique qualitative studies. A description and explanation of an explanatory model arising from the synthesis was then described. This was followed by a description of the methods and findings of a realist evaluation based on in-depth data collected from 86 participants in three UK study sites (2 in England and 1 in Scotland). Study participants were: Service users in regular contact with services; Service users not in regular contact with services; Core service staff; Core service managers; Non-core services staff; and Service commissioners. The webinar concludes with an opportunity for observations, insights, and questions from webinar participants
About the speaker
Steve MacGillivray is the lead of the Substance Use Research Group in the School of Health Sciences, University of Dundee. He has a background in Psychology and a PhD in Health Services Research. He has worked in drug harm reduction services in the past and as an academic in Psychiatry, General Practice, Epidemiology and Public Health, and Mother and Child Health. He has a track record of research within the field of mental health, particularly regarding the prescribing, efficacy, tolerability, and safety of antidepressants. His research also focuses on understanding the optimal delivery of services providing Opiate Substitution Therapy and/or Needle and Syringe Programmes, reducing health inequalities, and improving access to and engagement with health services. He has expertise in conducting meta-analyses of randomized controlled trials, meta-syntheses of qualitative studies, rapid evidence reviews for policy, realist reviews, realist evaluation, and in-depth qualitative studies.
To the endu welcome to the endu weekly webinar I’m Katherine fley a researcher at the national drug and alcohol Research Center and I will be chairing your webinar today I’d like to pay my respects to the traditional custodians of the many lands on which we live and
Work in which for the panelist and myself today is gbanga country we pay our respects to Elders past present and emerging and extend that respect to any first nation’s people here today well I’m very much looking forward to today’s presentation we’ll be hearing about a study that sought to determine
Optimal access to and engagement with uh Service delivery for the provision of opiate substitution therapy and all needle and syringe programs in the UK quite in the mouthful and by the sound of it it’s going to be a really interesting presentation I’m delighted to introduce our speaker on this important topic
Associate professor Steve r mcil r um now Steve is lead of the substance use research group in the school of health sciences at the University of Dundee uh he has a background in Psychology and a PhD in Health Services Research and Steve has worked in harm reduction Services as and as an academic
In Psychiatry general practice epidemiology and public health and mother and child health so a wide range of expertise there I also have the pleasure of introducing Dr Allison seele who will be joining us a little later for the panel discussion Dr seele is a regional doctor who wears many hats her
Clinical work spands Primary Care as well as the hospital system with roles in opiod substitution therapy and Women’s Health Allison’s important clinical work is complemented by her work in the University sector where she is a senior lecturer at the unsw rural clinical School in cops Harbor and a
Senior research fellow at the national drug and alcohol Research Center we’ll have time for questions at the end of Steve’s presentation so please do send them through and a special reminder to send your questions through the q& a function rather than the chat function I will present these questions to the
Panel at the end and we’ll Endeavor to get through as many as I can so please settle back and enjoy the presentation and Steve I would invite you to start and a warm welcome thank you very much Katherine and um thank you to endar for facilitating this and already I’ve
Enjoyed visiting and dark I’ve I’ve seen um I’ve seen practice and I’ve also seen lots of research so I feel very welcomed in the country thank you um so I’m going to kind of try and it’ll be fairly high level because there is an awful lot of
Detail of the of the study that I just won’t be able to cover in the time but I want to try and give you a flavor of what we’ve done why we’ve done it and what we found um of course it was a a collaboration I’ve got lots of co-ops
There um a fantastic team across um the UK okay but particularly I’d like to um mention Peter mccullock and April Shaw they were the ones really the the the heart and soul of this entire project and indeed they will be first authors on any Publications in the final report
Which is due out at the end of this year um they’re just so fantastic they know the service well they accessed all the data they collected most of the data and we were involved in analyzing that together okay so I’m going to tell you about understanding the contextual
Factors about OST and NSP specifically as they relate to um improving access and engagement with services so in order to get the funding of course we um ah this all worked there we go um we we um we of course um sort of argue for the need um and essentially in the UK
It’s the NR National Institute for health research that funded this um in the UK we have one of the highest rates of drug related deaths in in Europe indeed the world and Scotland is indeed World leading in that regard um we’ve had recent major outbreaks of HIV and we
Need to minimize hcv transmission we know that OST and NSP services are effective for a whole range of outcomes there’s lots of good evidence for that but lots of people aren’t accessing them or if they are they’re dropping out so we need to understand how Services can be more effective in promoting access
And engagement and retention um of people who use drugs people who inject drugs to prevent reduce harms and deaths so the overall study a was to generate in-depth knowledge of the contextual factors and mechanisms that influence the use and nonuse of OST and NSP and as I say it’s optimal Service delivery in
This entire project is conceived around successes in Access engagement retention and successful exit from service it was and still is a multimethod study um throughout we have patient and public involvement as nhr like to call them we like to call it lived and living experience and it was a
Multiphase um with several objectives so phase one um involved a metasynthesis not um met objective one and I’m going to focus on that today um and an online survey I’m not going to mention that but um anything I don’t mention will be available in a a full report um that I
Can certainly share with endar and anyone that wants it phase two was a a realist evaluation um and that met objective three and I’m going to talk about that and as part of a realist evaluation what you have to do is develop an initial program Theory and then that informs a refined program
Theory through data collection I’m going to describe this in a bit more detail and that leads to phase two the second part of phase two which is the costing implications of the output from our refined program Theory and that is currently in the hands of our absolutely fantastic Health economics team in
Bristol they’re currently Twizzlers as we speak so I won’t be speaking to that either today so the main data I’m going to mention today um regards a metasynthesis of 63 qualitative studies and a realist evaluation using a site case study approach which involved 86 study participants from three UK sites so I’ll
Talk a little bit more about that so metasynthesis why why do that well we know that there are previous reviews out there on this kind of issue about treatment uptake and so on um but they’ve tended to pretty much focus on barriers and facilitators and list or describe those factors with limited or
Conceptual theortical transformation of the data so what we thought we would do is first of all is to um conduct a meta synthesis to identify and create a better understanding of these contextual factors whilst also focusing on the barers and facilitators the impact on use of
Services and as a as a really important aspect of the me synthesis was to use those findings to inform the conduct of the subsequent realist evaluation so to inform an initial program Theory um and we’ll come to that just bit further down the line so the synthesis um I’m just
Going to give you this sort of high level um the detailed account of the methodology is available we um published a prior protocol um with Prospero we conducted a comprehensive search of multiple key sources of data uh we conducted critical appraisal and we followed um broadly the the methodology
Of noblet and hair in terms of analysis and synthesis our inclusion criteria for studies were that they should ought to understand the optimal provision of any of these Services OST or NSP from the perspectives of any key stakeholders whatsoever whether that be staff service users anything but that the study must
Have some relationship to understanding or the impact of access engagement retention and successful exit so here’s the uh the sort of newer um Prisma flow diagram um that shows the uh kind of flow of the finding of studies I mean overall the short headline is that there were more than
2,000 um possible um records that were included and screened and subsequently um included in the review were 63 studies from 67 reports 10 of which um focused on NSP and 53 on OST so 63 studies 38 of these studies were published in The Last 5 Years I
Should say one of the other exclusion criteria was anything published before the year 200000 is an arbitary kind of cut off of recency um so 38 um published in the last five years and 44 of the 63 were assessed as methodologically probably weak we dichotomized in terms of possibly strong probably weak uh
Determined by how well they did in terms of triangulation of data theoretical sampling rigor reflexivity credibility relevance and so on the studies um well were from around the world but not surprisingly like so many um systematic reviews the vast majority were from North America or Europe of course UK isn’t in Europe now
So we have our own little setting there um you’ll see that six of the studies 11% um helded from Australia and if you look at the study participants you can pretty much see that the vast majority of these um studies were people who were service users that pwi should also have
Forward slash people who use drugs as well as inject drugs uh so the vast majority were um service users themselves so 20 of the included studies 13 ostd and NS and seven NSP included nearly 500 staff participants and 53 studies 45 OST and NSP included about two and a half thousand service user
Participants um I just put this as an interesting note at the bottom that none of the studies as far as we could tell included any commissioners of services that’s important when we come to our realist evaluation so the analysis broadly follows um a quite a laborious um draw through all of the
Data that’s presented in the individual papers and a kind of extraction and Analysis of first order constructs that are found in those papers and those are direct quotes of study participants so primary data if you like and then second order constructs are those author interpretations which also include
Thematic analysis and so on so we coded at those levels and then we related and translated the concepts and the constructs we clustered similar Concepts and we translated original Concepts into reciprocating Concepts from others um studies so just to give you an example of some of the first order and second
Order constructs so first order um from the review by bodko 2016 a direct quote from a service user for me it is an important argument even if I want to be enrolled I’m afraid that I will be very limited in my movements I like to travel with my children to different places I’m
Like everybody else this is the reason and also the fear that I have no job I fear they will not employ me God forbid the very enrollment in the program limits and restricts me in many ways so you can see that that relates to access and fear around um sort of problems with
With accessing the service the second order construct in this kind of um s similar area is where Damon etal um and this is an author interpretation of their analysis of the primary data participant accounts Illustrated how perceived coercion during ostd initiation corresponded to lower levels of trust and negative views towards OST
Which sometimes led to OST discontinuation so you can see how that speaks to issues around um discontinuation and thus um you know engagement and so on and issues around coercion and so on so you can see how we can actually start to triangulate some of the first order and second order
Constructs to try and explain and understand issues around access and engagement so we’ve got lots and lots of that kind of data and then we have this magical exercise which I I really enjoy and we use the kind of whiteboarding exercise where we actually put all of these Concepts all of these constructs
And so on um onto a whiteboard and we start to map them and look at relationships uh and so on and start to develop our analysis and this is just like a zoom in of one part of that whiteboard um and you can see that one
Of the issues that kind of loomed was the concept of power and control and it came from different areas to do with things to do with autonomy feeling controlled by effects of medication coercion and that could be direct or indirect and systems and services themselves the rules and contracts uh
Not knowing the game change of rules not being part of creating the rules staff themselves Services being inflexible judgmental oppressive and controlling and don’t forget all of this um evidence is entirely inductive we’re not mapping anything onto this this is all rising up from the um from the data in in the studies
Themselves and then of course we’ve we’ve kind of evidenced where um lots of um you know how rich or not this data is so for example we have a a table which um which shows for each study where it contributed so for example we have this kind of third order construct that we’ve
We’ve developed from those first and second order constructs around the issue of power and control of which there are some sub themes one of them being restriction and inflexibility for example and you can see these are individual studies that contribute meaningful data to understand those specific things so we have that
Throughout the data all of this will be available in in the report and the subsequent Publications and then then you can have a general map of where the studies contribute to these higher order Concepts or themes that we developed um and you’ll see the labels there power and control stigma knowledge and
Information and goals needs and preferences and I’m going to say a bit more about those but what you can notice and and this is um just an abbreviation of the a long table of all the 63 studies you can see that actually there’s quite a rich data set across all of these
Um third order constructs so I’ve mentioned power and control um being kind of one of the high level Concepts here and across the evidence findings indicate that service users feel powerlessness over regulated andless lack control in their dealings with OST and NSP and also there’s good evidence
Across a wide range of studies settings and countries the services can be inflexible restrictive with coercive practices es which lead to a lack of autonomy dissatisfaction engender various fears and thus act as a barrier to service uptake and continued engagement the second kind of high level construct is that of stigma not
Surprisingly I mean so many studies mention or Focus stigma have that as a as a main theme of of their discussion and the evidence when you pull it suggests that stigmatization within systems and services as well as enacted stigma from service staff and from other service users are further
Barriers um to access engagement and so on particularly access and indeed a high level of sort of monitoring and surveillance that needs to be that happens in Services impacts directly on on service user um identity trust experiences of confidentiality anonymity and thus influence access engagement with retention and exit if anyone’s aware of
Any of this literature in any way shape or form this this will not be a surprise whatsoever the other um High third order construct that that was important um was knowledge and information such that services on knowledge and beliefs and misbeliefs and so on of the potential impacts and consequences of treatment in
Relation to drug harms all influence their decisions around uptake and engagement and knowledge and information highlights the importance of service users being made aware of services so that knowledge about what services are available and when and how do you access them so that they can make informed decisions and it also underlines the
Importance of partnership working between services to ensure that they’re working in a common way and that they disseminate and communicate um and enhance awareness of services and roots of access and so on so that that that was quite an important um set findings across all the studies and then a really
Rich um data set across many studies was the issue of what we’ve termed goals needs and preferences and that’s important to have that kind of multi um concept heading because it’s not just about goals of treatment it’s not just about you know needs of treatment and immediate needs there are wider life
Needs and there are also preferences people have different expectations people have different needs and different preferences to meet those um and so the evidence suggests that person centered services that are capable of meeting these different treatment goals wider needs and providing options and choice are more effective um and better
Received and the provision of a range of services offered at different thresholds um for which service users have Choice also appears to be important and services that provide options and choice regarding wider supports especially regarding on-site wraparound service models um may actually help to facilitate successful access engagement retention and
Exit so one thing I I kind of I suppose promised early on is um you know the other reviews that have done this sort of barriers and facilitators haven’t actually gone on to do any of this further on analysis and actually postulate an explanatory model which could account for the data which would
Be interpretive which would keep the understanding of contextual dimensions and indicate interrelations and allow people to actually look at it and map their um experience and service to it and so this is the um the model the explanatory model that we’ve come up with and and essentially service users
Are at the middle the center of that um service user Centric the actual outcomes of access engagement retention and exit are just around that around the service user and outside of that we’ve got those wider cultural political and organizational um influences and issues but all of the data that we’ve collected
Speaks to these interrelated um groups of power and control knowledge goals needs and preferences and stigma which all interact and overlap to influence access engagement retention experiences and so on so that’s a Whistle Stop tour high level of the um of the metasynthesis and it answers its own questions too
About you know what are the main drivers of these access and engagement issues and so on but also it provides an output to inform the realist evaluation so I’m just going to go on now and just start from the beginning of our realist evaluation proper and describe that so
They aim essentially was to undertake a qualitative in-depth realist evaluation using a case study approach to establish the contexts and mechanisms that impact on the use and nonuse of OST and NSP in the UK and a realist evaluation has um well three main steps and and actually if you read Around realist
Evaluation um and you read any outputs any papers that describe them they do vary quite a bit but there’s there’s kind of a a core approach and this core approach is firstly to develop an initial program Theory it’s where you’ve got you describe context and related mechanisms that are theorized to result
In optimal service provision for whatever your outcomes or outputs are are deemed to be step two then once you’ve got that initial program theme um is to go and test it so you test that via the um in our case via qualitative interviews with key stakeholders you go and collect
Evidence hold that up to scrutiny test it and that should lead towards the development of a refined program theory that is explanatory um and can answer the question of you know how do you what is an optimal service what does an optimal service look like how does it operate in
Order to um improve access engagement with and exit so the initial program theory is the first thing and that’s identified and developed by generating hypotheses about the potential interactions between contexts mechanisms and outcomes and if you’re not familiar with this this might sound a bit abstract just now but I am going to
Actually show you how we’ve done that and so really these CMO configurations as they’re called can help to show how and for whom and in what ways of particular program or service can operate optimally so what you might note here is this is this is step one the initial
Program Theory and this is how we went about developing that and you’ll see at the middle of that um is the explanatory model that I showed you at the end of the metasynthesis so that actually formed quite a core um to influence the description of initial program Theory so
The metasynthesis output we also conducted a survey of um all commissioners of services across the whole of the UK so that’s Ireland England Wales and Scotland um we conducted a documentary policy analysis of all policies in the home nations in the UK we’ve had various um PPI groups lived experience input and other
Stakeholders key stakeholders staff members and so on and experts in the field um in order to actually put this kind of through the mill to describe what initial program Theory might look like what the context mechanisms and outcomes were using the output of the metasynthesis as a starting
Point and this is what we came up with I’m showing you high level stuff but there’s lots of things underneath this but these are the main context mechanisms and outcomes so you can see context plus mechanism equals outcome so in the context of power and control which we’ve
Termed the context of controlling and restrictive Services um if service users have the choice between different thresholds low threshold medium threshold services and so on that choice they’re more likely to access and continue engagement if service users have a degree of power via person centered approach to make decisions Improvement in outcomes if
Service users are supported to develop strength-based competen and self-esteem leading to positive social networks a sense of belonging and purpose in life Improvement service user groups encourage engagement and roots of advocacy to ensure that they have a voice in the services provided and then the second context the context of stigmatization and
Alienation staff recognize the importance of confidentiality and non-stigmatizing approach which leads to positive relationships with and increased confidence and Trust of Serv users and then service users are supported to develop strength-based competencies and self-esteem leading to positive social networks sense of belonging and so on and then service
Users are supported to increase their recovery Capital through engagement with communities of interest to them increasing social connectedness and support and in the context of knowledge and information the context of misunderstanding and uncertainty then if partnership working is encouraged if there’s effective service dissemination in good informative peer Network
Programs if all staff are trained in in in drug use issues harm reduction and safeguarding then that leads to successful access engagement and so on and then the fifth the the fourth um context is the context of goals needs and preferences which is the context of personalized
Services and uh the mechanisms that um broadly were generated from this context were that single Shar recording system locally and nationally was required to help manage um care planning and so on and PE movement of people through systems a commitment to providing services that facilitate a shared shared ethos understanding and responsibility
Between all key stakeholders Services providing a range of options staff being supported and resourc to overcome the the barriers that they have to deliver good treatment outcomes appointments taking account being personalized and Tak taking account of of personal circumstances and then meaning consultation with service users such that their needs goals and preferences
Can be identified in me and one thing you should notice from this is the loss of this language is actually quite negative the context of controlling and restrictive Services the context of stigmatization and alienation this this is all generated from the evidence particularly that kind of qualitative in-depth evidence and and it’s something
That we through subsequent realist evaluation we come to challenge and and turn around quite significantly so step two then is start to go and test this IP to go out and conduct semi structured in-depth interviews with a wide range of of key stakeholders and we did this in three um
Three sites across the UK one in the west of Scotland one in the southwest of England and one in London and a couple of Bs in London London and we’ve maintained anonymity throughout such that we we did interview people in some small services so we’ve not identified
Specific um areas um so just more General sorts of areas and the recruitment we aimed for 72 overall we achieved 86 and you can see that we interviewed service users in contact and using Services now service users who may have used in the past but were out of
Contact non core services staff staff in core Drug and Alcohol Services managers of those core services and then commissioners of services and just to give you a quick flavor of the study site characteristics um essentially if you look at the notes all four sites were mainly Urban so you know they do have
Some potential to reach rural populations and that’s one limitation that we have um a range of U of of drug related death rate um sites varied regarding the richness of Multicultural communities they all have a degree of shared care with with GPS all Sites have Pathways that include
Specialist medical models all Sites have Pathways that include specialist Pharmacy models all Sites have examples of fixed and Outreach models and third sector organizations were only part of Pathways in the two English sites but not not Scottish sites and the NHS involved to some degree in part ways across all the
Sites so the in-depth interviews um generated a wide range of verbatim views uh the data suggested that stakeholder views actually viewed Services as effective and important uh with many deficits so there was really quite a positive spin on a lot of this um and across in between sites there are
Examples of bet best practice but also weaknesses and where service needs to be improved so what we did then through this analytical process was um we refined that IP those context mechanisms and outcomes that we had and it indicated that power and control is actually better understood as agency and
Empowerment stigma as self-esteem and respect knowledge and information as knowledge and communication and goals needs and preferences actually needed no reconceptualization as that was already very person Centric uh and continued to be of particular importance but a new context emerged that of resources and demands uh actually one thing I didn’t
Mention is there was some things in the metasynthesis they didn’t really map to anything but they kind of related to staff well-being and so on um they are actually now captured in this this new context of resources and demands which which actually looms quite important so just to say something about
Resources and demands it’s about understanding service demands to inform Service delivery and design so that resources can be allocated appropriately that’s one of the main um issues here but also that staff are supported in resource that overcome the barriers and their ability to affect good treatment outcomes po Services need adequate
Reliable and sustained resources to create the right circumstances for good Recruitment and Retention of Staff because that was a massive issue that you know was different across different sites and in different areas but um certainly recruitment and and retention of of um well-trained staff was an issue
Funding of core drug services and wider drug service related initiatives needs to be sufficient reliable and accessible and a range of key performance indicators um were required to be measured to to direct effective Service delivery ensuring that it remains um person centered and I’ll say something a bit more about
That so what we have is this shift from a kind of explanatory model towards a more refined program Theory we’ve now plugged in resources and demands to that model um and but our refinements also indicated that we needed to shift these mechanisms a little bit so there’s a
Reduction in the number of mechanisms for the first four and then we’ve got new mechanisms coming in for the the new context of resources and demands and then further refinements to order to capture the person’s centeredness and a lot of this was determined by input from different key stakeholders lived and
Live experience and so on and this is where we got to to generate remember this is top line so we have a lot of sort of details underneath this um to generate these new context mechanisms and outcomes for our refined program Theory so now our agency and empowerment
Context is now the context of shared decision making service users are empowered service us Services should be low threshold with a range of tailored options service users have access to those involved in their care direct access self-esteem and respect now no longer stigma in the context of identity and
Belonging and it’s about you know recognizing and actualizing the importance of confidentiality and on stigmatizing approach across the service and that service users are supported to develop strength-based competencies knowledge and communication was about proactive partnership working embedded peer Network programs staff having the Knowledge and Skills U and goals needs and preferences were
About recording systems those sort of care planning and so on systems Being Fit for purpose uh commitment to Pro providing facilities and services that had a share um ethos a full range of services um a very wide range of services um that that are needed and that are not always
Provided um and appointments are personalized and taking count um individ idual needs so that Services can be flexible and shift to individual need and then I’ve sort of mentioned some of the resources and demands thing about understanding demands um we know that lots of people who are making decisions
About how um resources should be deployed and and how Services should be configured actually don’t understand or know um what’s happening on the ground um staff should be supported and resourced core Services adequate reliable resources and funding is um sufficient and reliable and so on so these are the mechanis these are
The context and mechanisms B analysis suggests that the hypothesized identified mechanisms actually have specific mechanisms of action and that these can be looked at in terms at two different levels system level systems level so high level strategic influences upon delivery of services and service level so that delivery Direct Delivery
But our analysis also identified the importance of mediating mechanisms so those things that can operate to increase the likelihood of those mechanisms reaching um successful outcomes I’m just going to try and operationalize some of that by just selecting a few of the mechanisms for you so here we have the the context of
Agency and empowerment shared decision making and a mechanism where we’re suggesting that service users are empowered via person centered approach to make decisions regarding treatment and the mechanisms of action to allow this to happen at systems level well funding of services and adequate Staffing levels comes through quite a
Bit also those safeguarding policies that are developed and enacted at the service level proactive case management care planning consistency of key worker negotiation of optimal dosing staff confidence knowledge experience purpose listening working at the pace of the service user timely access to treatment informed Choice a whole range of
Different mechanisms of action which can then mediate through self-efficacy motivation and Trust to lead to Improvement in the outcomes a few example quotes here um empowered via person centered approach to make dis decisions regarding treatment so in an optimal sense so I did take home medication when I went
Went on holiday I went camping with some friends and I did the take home Doses and it was lovely it just made me feel like a completely normal person like it’s not even a thing I love it I assumed it was because I had to prove
Myself I had to prove that I was not going to abuse it and I think now it’s almost like having a reward taking home doses so service user from site site B feeling empowered and then we have more suboptimal which is the lack of flexibility within the system and the
Site a manager reflects on that if people are working they can only be seen after working hours then we are flexible as much as we can around that so kind of optimal but suboptimal and maybe not as flexible as what we would be ideal um so moving on to um an example
From the second context self-esteem and respect identity and belonging and specific mechanism where service users are supported to develop strength-based competencies recovery capital and self-esteem funding of services and Staffing capacity and capability are important systems level mechanisms um but in terms of service level peer workers are are incredibly important and
Help navigate services and choice strength-based approach from the beginning of the treatment pathway is important focus on issues Beyond prescribing time for wider and more supportive conversations consistent keyworker sign posting provision of additional activities mobilizing um recovery capital and leading to um mediated through positive social networks belonging confidence
Self-esteem now I’ve got example quotes here which really do bring it alive and if I’ve got any time I might go back to some of these but I just want to cover um each of an example from each of these mechanism in case we run out of time and
I definitely want to leave um a chance for questions so the context of knowledge and communication informed decision-making peer Network program is embedded into core drug Services systems level there should be adequate and sufficient funding of peer programs peer capacity and capability um needs to be delivered and dedicated space the
Infrastructure from which to run peer involvement programs these really um came up as a really important um part of Service delivery that were often unil and not quite embedded um so peers embedded within each part of the path pathway of the service level um mechanism isms informal and formal approaches to their involvement
Formalized approaches to appointing and employing cor funded peer coordinators and peer team leaders and so on training for for for peer um for peers and mediating mechanisms were actually this was really important in gendering trust in service users in confidence in belonging in purpose and also in reducing burden on core drug service
Staff themselves some excellent quotes we really do have lots and lots of detailed um quotations that support this and in terms of the goals needs and preferences quite a rich data set around this the mechanism of a commitment to provide services to facilitate a shared ethos was really
Quite important um and there are systems level policies in Scotland for example we have uh we have the Scottish government um LED medication assisted treatment standards about how Services should be delivered and everyone can aspire to um to those but service design and delivery is should be directed by
Service user goals needs and preferences itself at that systems level and then at a service level shared understanding and responsibility close formal working relationships between different Services negotiation and agreement of shared care planning and opportunities for inter and cross agency training and meetings was seen as absolutely crucial and it’s
Iated through this shared ethos that improves access engagement and delivery of the service and then just one example of resources and demands and there are quite a few um mechanisms in this one but this one is about a range of key performance indicators which relates to
This idea that you know there are these hard and soft targets that that that but mostly it’s the hard targets that Services have to meet and so the argument is that there should be this range of key performance indic indicators and at a systems level resources should be directed towards
Achieving results in strategic priority areas and taking account of not just hard targets but soft and at the service level that there should be reliable capture of those um different outcomes um there should be measurement of contextual information around different outcomes and awareness and measurement of hidden outcomes and this is mediated through
Services remaining person centered um such the services are improved so it’s kind of a really fast Whistle Stop tour through some of the data um and I just wanted to I’ve got a couple of minutes because I do want to kind of leave the voice of of um some of
The participants of this on here so I’ve just got a couple of quotes that I want to to read to you one is regards short-term funding so resources and demand short-term funding it’s such a challenge within the third sector this is a non-core staff members so not part
Of the core drug service but still delivering drug Services because you’re constantly on short-term funding contracts and the funding is never extended because it’s good work you’re then having to find another funding pot and slightly shift your focus to fit into that funding pot so it does mean in
My view that you sometimes lose some of the efforts of what you’re trying to do because there’s not necessarily the scope to have this kind of natural learning and progression in any piece of work I think our ambition as an organization exceeds our ability financially to deliver I would say that
Every single staff member goes way above and beyond and I think that’s a third sector trait and perhaps it’s a statutory trait as well it is because other people quote the same in statut TR I don’t know I can’t speak to that experience but you always go over and
You work extra and you go well beyond and your job description is because you’re there and you’re working directly with people so of course you would and that’s one of the things that came through this realist synthesis that we did speaking to these key key stakeholders about what works and what
Doesn’t work is the examples of people going above and beyond um in restrictions um to deliver services but that has implications for retention and recruitment of Staff burnout and so on um there are many other quotes and so on that I could uh could mention I’ll stop there and leave some time for
Questions thanks for listening thank you Steve um terrific presentation and um really interesting work uh so many questions uh one thing that struck me is uh that word powerlessness and the voice of people so really important work bringing together the evidence that we have with um the perspectives and views of the people
That are most affected by Service delivery so congratulations a really important and big piece of work um Allison I would like to invite you to now uh just give a couple of minutes reflection turn your camera on you’re on uh let us know what you’re thinking about this presentation and Steve if you
Would like to stop sharing your screen we’ll be able to see Allison okay that’s the back of my office at University of done the thank you thank you thanks Steve for stepping us through a very very complicated review so clearly and logically um it was very
Easy to follow and I really like that realist review um with the use of mechanism to really get to the nitty-gritty of why things succeed or don’t it seems like a really fantastic model U to get to where we need to um really resonated as a opioid agon therapy prescriber we really need
To have that patience centered client centered consumer centered service user centered approach um and sort of you know thinking about the way we think of services um you know that really strong Therapeutic Alliance really came through um through what you were talking about and that when you’re
Talking about those um five areas around agency empowerment um self-esteem and respect that you know that reshaping of an opio dependence use problem as a chronic disease model rather than you know a societal issue or a stigma was really really important so I really enjoyed that you thank you Allison thanks for
Joining us um so Steve we’ve got a couple of questions on the panel firstly Grace and I apologize if I get your name wrong Grace prel uh has said really great empathetic approach appreciate that comment um James McGregor has asked Steve you mentioned Commissioners would you mind just explaining who you mean by
That yeah well yeah actually I did think about that because I know that that’s one of the probably the differences um in terms of um you know the Australian context and so on but I mean broadly speaking Commissioners and the Commissioners are usually kind of senior individuals within um within well we
Have Healthcare trusts and so on we have health boards and what have you actually you know look to what service needs are and then make the case to um Treasury and so on for you know the the health budget to say what’s the budget envelope that we’ve got to deliver
Services over this particular time so an awful lot of data collection goes in um around you know how how are we working what’s working what isn’t what do we need to do and there’s lots of consultation and you know managers and meet and so on um and budgets are then
Accordingly deployed now so those those um those Commissioners are senior managers who manage services so they sit above the direct service provision and actually look to um over oversee management of the service um and they’re not all the same it would seem you know because some actually do
Have more of a background or or a bit more of a knowledge of actual Service delivery While others don’t you know others have come in from a management perspective and not from from the coal face um but the the commissioner voice um has been completely missing from any
Of the literature we’ve seen before and it’s why we with some of the rich data that we have we only had six Commissioners um but um the rich data that we have that bears on thinking about um kpis thinking about you know the cycle of funding so for example some
Some areas have managed and this is by D of the commissioner themselves they’ve managed to negotiate um lengthy budgetary periods such that you know often it’s usually about a three-year funding cycle and then you’ve got to go through it all again so what some people were talking
About is like oh we have these great initiatives everything’s going well and then suddenly Everything’s changed we’ve no longer got the funding support that we’re into the next funding cycle and we’ve got different priorities and so on but some have managed to negotiate a kind of a a 3 plus seven a 10year
Funding cycle such that initiatives really can um continue on so I I I don’t know if that answers your question fully enough um you know like I I could go into the job description of a commissioner perhaps but yeah I’m not sure thank you Steve um James said that makes
Sense slightly different context in Australia which um is really important to note but great inclusion thank you um we’ve got a question here from Jennifer Holmes welcome Jennifer uh thanks Steve excellent model uh please could you provide a little more detail on the Strategic indicators oh okay strategic indicators
In terms of um well which ones particularly kpis the kpis the kpis yeah um oh can I quickly share again well can I read a quote for can I read a quote for you this is this is a quote from commissioner in site B and who is it that you need to
Convince that key performance indicators have to be more indicative of these softer targets as well it starts with the national level because if I can talk to elected members I can talk talk to the chief exec and I can talk to the directors in the building but they will
Always take you back to well these are what the indicators are and these are what we are measured by so if there isn’t a national strategy and there isn’t a national framework around these qualitative elements then the powers that be locally will always say this is
What it is what we get measured by and it doesn’t look good and I’m I’m I’m in the no to agree to a degree I’m in that box as well because you know like I I like to see greens across the board I mean don’t we we don’t like to see Reds
On there because it it’s just that visceral element to it isn’t it when you see a red it’s like God you know so that quote speaks to those kind of hard important um targets you know I mean you know how many people are being seen you
Know so that’s just a number it’s not about the quality of the nature of that service you know how many adverse outcomes how many people are receiving how many people are reducing dose or on a maintenance dose or you know these kind of hard are important
Facts um so I don’t know if that partly speaks to to to the query thanks Dave thanks Jennifer um any further questions there please feel free to pop in um and we’ll come back to those um I’m really uh Curious this kind of work is is quite complex and challenging particularly working across
So many different you know and stakeholder groups I wonder what the key challenges were for the research team and how they overcame those the million dooll question um in engaging with people to actually have that conversation um about what’s needed well the me yeah challenges there are always
Challenges I mean I I I was brought up in research to believe that there are 10 changes at the beginning of any project 20 in the middle and another 10 at the end you know the challenges were Legion in this not least not least the fact
That we um we pretty much kicked off at the time of coid so imagine trying to do a national survey of um all of the Commissioners in the UK at a time of coid when everyone’s head is elsewhere and yeah and so that was kind of we we
We generated some interesting data from that survey but the response rate if I remember was about 18% so you know and that was despite many kind of iterations and rounds and so on um we had problems because of coid in terms of accessing the sites of getting the rights to be
Able to go in um you know of getting ethics approval um teams were off people were down with coid you know there were little kind of narrow narrowings of pipelines of getting things done that were you know down to one or two people who were suddenly not available whole
Systems and services didn’t happen so it’s no surprised that the two-year study has now become a three-year study and we’ve had no cost extensions we’ve lost staff as well um but one thing and how we really overcame overcame all of these challenges was tenacity um was having two of the finest
Um researchers I’ve ever worked with um in Peter in April who just really know Services know how to access the stakeholders you know they they’ve been at the coace they’ve they’ve they they speak the language they walk the walk they were fantastic and without them the project would would absolutely
Be nothing um and so and even when it came to analysis you know it’s getting our heads together and drawing in the expertise from from the team but so yeah challenges are plenty I touch on only a few terrific thanks Steve I think everyone can probably relate to that um
Idea particularly through Co of how challenging it can be and Service delivery in particular for people was really difficult um and I think what’s really nice about that is engaging with the right people and the people that actually know what is happening at the coace um to to ensure that you’re you’re
Sort of doing something that is feasible um which is is a challenge in itself but yeah fantastic work I guess a final question would be um oh hold on a minute we have another question here so I’ll go to that first uh I would like to know if
You have witnessed changes across your time in this area when it comes to treatment availability and outcomes in Scotland um being new to the area and had recently looked at Scottish data was surprised uh Grace was surprised about the scale of some of these problems um and the lack of historical context for
Contextualizing all this yeah no I mean that’s a fair point I mean look you go anywhere in the world and patterns change behaviors change drugs of choice change um but one thing that remains is is you know there is a problem with um substances affecting people’s lives and
Um and and you know Services need to be delivered so um in Scotland there’s no um I mean I first worked in the drug problem service in Dundee um 30 years ago and of course the big issue then from the 80s was HIV and the shift of
Harm reduction and that’s kind of still where we’re at you know which is which is good um but um changing pnes I mean dunde and Scotland are World leading in drug desks partly that’s driven by um kind of Street bends of dzines and so on
Poly drug use and what have you so you know and and do Services change well do they change quickly enough to probably not um and hence why we need to be doing this research hence why we’ve got the mat standards um in in Scotland to try and
Drive that change but it’s a slow process but nevertheless across the board whether Scotland whether England what we find is that there are areas not every area is delivering services in exactly the same way and they all have slightly different challenges and some are doing some things better than others so this talk
Of optimal Service delivery is actually a theoretical position that we have in the middle such that anyone that’s delivering Services whether in Scotland or wherever can look at this and think where how do we measure up to to these mechanisms how are we delivering on
These me do we want to is that how our service is configured and so on so I I think that’s one of the implications from this research is that we could potentially provide this framework that you can map your service to um but I think anyone looking at this I mean
Sometimes you do this kind of work and people you know it’s kind of well you state in the bleeding obvious you know we already knew that and well in some ways yes but this is entirely inductive and it does actually I think lay out in a fairly mechanistic and and easy to
Follow away a way that you can map your service to I think well where can we actually where are we falling down and where are we doing well let’s focus on those areas where we’re we’re going Amber now um yeah I’ve rambled a bit around that question do apologize thank
You Steve really really interesting to hear and I was going to ask for one very quick recommendation what would be your very quick recommendation in this last minute or so that we have from your work you know I think a really quick recommendation is to whilst we recognize
And I really made a point of at the end of talking about this whilst we recognize the fantastic amazing job that individuals do and they going above and beyond it is not sustainable as a as an approach and that whatever we do we we celebrate that absolutely but we need to
Support that we need to Resource that we need to fund that we need to harness that and we need to allow people to be able to do a job that they is incredibly challenging and that they absolutely love so that they can continue to do
That and be the best kind of you know Agent of Change so it would be that I I think thank you Steve thank you so much um just like to take this minute to say thank you for coming to Australia and sharing your insights with us Allison
Thank you for com Along coming along as well we’ve come to the end of our time so we’ll just share our upcoming uh webinars and just let you know to please make contact with us if you’d like to hear from Steve um or Allison in relation to what’s happening in
Australia and the work that she’s doing and we thank you all for coming along and you can see we’ve got Dr Sam college frisbee next week a really exciting presentation please come along and join us thank you thanks for having me