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STREET SEX WORKER INITIATIVE
A low threshold initiative was developed for street sex workers who
elected to engage with it, and who were provided with 30mg oral
methadone. They could pick up on any or all days, seven days a week,
giving them the option of working and a safety net. Two pharmacies
were part of the team and would work in partnership, closely
monitoring risk. The expectation of the sex worker was that they
would attend a three-monthly clinic. Its format was devised by
service users and access was available for:
• rape crisis intervention
genito-urinary medicine services for smear tests and sexually shared
• infections,
high vaginal swabs and any necessary treatments
family
planning
for depot contraception injections
•
• midwives for pregnant service users
• needle and syringe exchange
• condom provision
• vaccination for hepatitis A and B
Direct referral to colposcopy and appointments was provided at the
time of attendance, as well as the ability to dress wounds, listen to
breathing to identify respiratory disorders, examine injecting sites,
monitor drug use and move into mainstream treatment if that was
what the person wanted. Apart from the obvious direct benefits for
service users it also improved relationships between services and the
sex workers’ access to these.
incorporated into a tender for Derbyshire treatment services at the beginning of
2017, and the new service went live in April 2017. The HIT do not carry a caseload,
but instead support key workers with their higher risk service users, and the sole
focus is on improving their physical and mental health and preventing drug-related
deaths.
Those with chronic and deteriorating physical health will have greater priority
placed on managing these conditions integrated with their substance misuse
treatment. Physical health assessments and advice will be provided by the HIT
nurses, including more routine care such as blood-borne virus testing and
vaccinations alongside ECG.
The role of nurses was central to the success of the Derby approach, and is
fundamental to the other examples provided. Over the past decade or so, nursing
and other clinical expertise has been lost – meaning that within drug and alcohol
treatment, as many of our service users age and require broader health and social
care, clinical expertise is less accessible. The multi-disciplinary team, which includes
those with clinical expertise working with other disciplines and those with lived
experience, has never been more important.
NHSSMPA is also part of a national working group led by the Royal College of
Psychiatrists and PHE, with third sector colleagues, that is trying to reverse the
reduction in addiction psychiatrists – an example of the sector responding to an
important workforce issue. It is at our peril that we do not ensure that drug and
alcohol services incorporate the correct blend of skills and disciplines, including
highly skilled clinicians.
Authors are Jon Shorrock, Avon and Wiltshire Mental Health Partnership NHS
Trust; Linda Johnstone, Cheshire and Wirral Partnership NHS Foundation Trust;
Martin Smith, Derbyshire Healthcare NHS Foundation Trust; Mike Flanagan, Surrey
and Borders Partnership NHS Foundation Trust. All are members of the NHS
Substance Misuse Provider Alliance (NHSSMPA).
why retaining an appropriately balanced and skilled work force is essential.
ENGAGING COMPLEX CLIENTS
Nursing staff learned compression bandaging to work with some difficult-to-engage
service users with venous leg ulcers. We worked with people who were not turning
up to the dressings clinic, not having doppler studies, continually having breakdown
of their ulcers, and suffering widespread infection, cellulitis and venous eczema.
We engaged with their GP practice and developed a shared care type approach.
We increased outreach to service users and managed their dressings as per the
care plan. We would make sure they attended doppler appointments where the GP
and nursing staff would manage the dressings. This allowed a relationship to
develop between the service user and the nursing team and allowed us to pull
back when the service user was fully engaged.
DERBY’S HIT
Derby Healthcare Foundation NHS Trust looked at their care delivery in an effort to
address the effect of diminishing resources. They devised a ‘red flag system’ to
identify service users most at risk of accidental overdose, through reviewing six
years of local mortality data.
The common themes that correlated this risk of accidental overdose were
largely expected – continued intravenous use of illicit drugs, erratic engagement,
poor physical and/or mental health. But less considered was hepatitis C status and
the link with those living in isolation. Other risk factors were a hospital admission
in the last 12 months and having a physical health condition such as chronic
obstructive pulmonary disease or a deep vein thrombosis. Being prescribed
additional medication with a sedating effect by their GP was also a marker.
Collecting and analysing this data identifying who was at risk led to the
creation of a health improvement team (HIT) in Derbyshire. This approach was
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‘Disinvestment and retendering
cycles have resulted in...
a significant loss of knowledge,
practice and skills, as provider
organisations design services that
try to manage the reduction in
budgets while still meeting need.’
March 2018 | drinkanddrugsnews | 21