Service Evaluation of Scotland's Take-Home Naloxone Programme

1 Introduction

1.1 In June 2013, the Scottish Government commissioned Blake Stevenson Ltd to undertake a Service Evaluation of Scotland's National Take-Home Naloxone (THN) programme. This evaluation complements other research that is ongoing or recently completed and focuses on the processes that have been put in place to implement the programme as well as on qualitative research with service users and practitioners.

1.2 The Scottish Government established the THN programme in 2010 following successful pilots in NHS Greater Glasgow and Clyde, NHS Lanarkshire and the Inverness area of NHS Highland. Naloxone is an opioid antagonist which can temporarily reverse the effects of an opioid overdose, providing more time for emergency services to arrive and treatment to be given to those who have experienced an overdose. The programme distributes naloxone using a Patient Group Direction (PGD) through supplying 'take-home' kits to those thought to be at risk of opioid overdose. Kits are supplied in community health settings as well as in prisons when prisoners are liberated.

1.3 The programme is Scottish Government-funded, centrally coordinated by a National Naloxone Advisory Group comprising experts from statutory and third sectors, and delivered by a National Coordinator (based at the Scottish Drugs Forum). Other key programme elements include: a national practitioner network, a national training and support officer, a national monitoring and evaluation programme delivered by NHS ISD Scotland, a peer educator initiative,^[2] national training and information resources, and specific support to Health Boards to deliver the programme in prisons.

Research aims and objectives

1.4 The aim of the research was to examine how the THN programme is being implemented across Scotland, in order to ensure that it is as effective as possible in achieving a reduction of opioid-related deaths.

1.5 The research objectives were to:

• examine the processes and structures put in place to implement the programme locally (to include a clear description of the different models that have been established);
• assess the effectiveness of identified processes and structures for the different stakeholders involved (i. service staff, ii. programme beneficiaries including those at risk of opioid overdose and their family members/carers/friends);
• provide an early indication of programme impact including consideration of the outcomes for those who have engaged with the programme, and whether the programme is reaching those who do not typically engage with drug treatment services; and
• establish the key lessons learned and the implications for policy and the future development and implementation of the programme.

1.6 The evaluation process was overseen by a Research Advisory Group which has met three times.

Methodology

1.7 We designed the methodology for the evaluation in three stages:

• Stage 1: mapping local models and reviewing existing data.
• Stage 2: in-depth qualitative work.
• Stage 3: analysis and report writing.

1.8 We provide a brief description of the methods used in each of the stages below.

Stage 1: Mapping local models and reviewing existing data

Scoping interviews

1.9 We undertook scoping interviews with eight key stakeholders in the THN programme at the start of the work in order to provide important contextual and background information for the research team.

Literature review

1.10 We completed a rapid literature review in August 2013. The purpose of the review was to provide background and contextual information for the research, and to guide the development of the research framework for the stage 2 fieldwork.

Mapping of local services

1.11 In order to gain an in-depth understanding of how the national THN programme is operating at Health Board level, we conducted an online survey with local naloxone coordinators in all 13 Health Boards participating in the national programme and received responses from all^[3]. This was followed by a telephone interview with the coordinators (with one exception where the survey was not returned until much later) where further explanation around the survey return was gathered. We also interviewed key Scottish Prison Service (SPS) staff and NHS staff working in prisons in order to build up a picture of the THN programme in Scottish prisons.

Online survey of service providers

1.12 We used an online survey with service providers and other key stakeholders so that as many providers as possible could give their views to the evaluation team. The survey of service providers was conducted across the 13 participating Health Boards. Local naloxone coordinators, the Scottish Government's Drugs Policy Unit, SPS, and the Scottish Naloxone Network (ScoNN) helped to publicise the survey to potential respondents.

1.13 We received 186 responses in total, with:

• responses from all Health Board areas;
• most respondents based in community settings (87%), 13% based in prison;
• 40% involved in naloxone training and supply; 31% involved in training only; 9% in supply only; and 8% identified themselves as the local naloxone lead;
• representation from a range of professional groups including nurses, CPNs or addictions nurses (38%) and voluntary sector workers (18%);
• most employed by the NHS (61%) or voluntary sector agencies (26%).

1.14 Appendix 5 contains the full analysis of the online survey.

Stage 2: in-depth qualitative fieldwork

1.15 In order to allow for more in-depth examination with service users and providers, as well as service users and their families, the main qualitative fieldwork focused on four Health Board case study areas. The four areas were selected after discussion at the Research Advisory Group based on the following: geography; size of Health Board area; the nature of the local programme; the number of prisons in each area; how easy it would be to gain access to the relevant staff; and whether the areas have peer networks in operation. The aim was to select areas that would ensure a good spread of interviewees from across different models. The four areas selected are described below:

Case Study A: a large urban Health Board with complex delivery of the programme through several Alcohol and Drug Partnerships, community addiction teams, pharmacies, third sector agencies and a peer trainer programme.

Case Study B: an area with small towns and rural areas with some pharmacy involvement.

Case Study C: a mixed urban/small town area with delivery of the programme mainly through community pharmacies in addition to nursing staff.

Case Study D: a smaller rural Health Board area where delivery is through the Community Addiction Team and third sector agencies.

1.16 We included prisons in three of the four case study areas (one area did not have a prison).

1.17 We conducted the following number of interviews (a full breakdown by case study area is provided in Appendix 1):

• 52 service providers were interviewed (including nurses, voluntary sector staff and managers, pharmacists, enhanced addictions casework staff in prisons, SPS managers, social workers, residential hostel staff in local authority run hostels and non-clinical community addictions team staff).
• 37 service users
• 11 service decliners
• 15 family members
• 7 peer trainers

1.18 As part of the above service user figures we interviewed thirteen former prisoners in the community and of the thirteen, twelve (three women and nine men) had all been naloxone trained. All had taken a kit on liberation. We also conducted interviews with staff in three prisons: we spoke to four nurses, two Enhanced Addictions Casework Service staff, and four managers.

1.19 In addition to the above we conducted an interview with the Chief Executive Officer of Scottish Families Affected by Alcohol and Drugs specifically to explore the issues relating to families.

1.20 The interviews with service providers lasted around an hour and those with service users, service decliners, family members and peer educators lasted between 10-60 minutes.

1.21 The interviews took place in the service provider's workplace, including pharmacies, drug treatment centres and Community Addiction Teams' premises. A few interviews with service users who live in more remote areas were undertaken by telephone with their prior agreement.

1.22 Appendix 4 contains the interview schedule for these interviews.

Stage 3: analysis and report writing

1.23 We undertook analysis of all the elements of research undertaken, checking for cross-cutting themes, similarities and dissimilarities and noting examples of interesting practice.

1.24 We produced a draft report which was commented on by all members of the Research Advisory Group and made amendments to produce the final report.

Limitations of the methodology

1.25 This was a service evaluation which examined in depth the processes and structures put in place to implement the programme, and assessed effectiveness in delivering the programme as well as assessing the impact of the service on key stakeholders. It explored the qualitative views of a sample of those who have experienced the programme and those who are engaged in providing it. It did not gather quantitative evidence on programme usage of kits as this is supplied by ISD. The evaluation did not require the consideration of any financial or value for money issues.

1.26 The recruitment of service users for qualitative interviews was facilitated by local statutory and voluntary addictions agencies. While we provided guidance on an ideal sample, we had limited control over the recruitment or selection of interviewees. It is possible that in some cases, there was a slight unintended bias towards those who were positive about the programme either where they had volunteered themselves or where staff had selected them because they knew what the views of the person were likely to be. However, the use of an external research team reduces the potential for response bias as participants are potentially less likely to say what they think the interviewer wants to hear than if the interviews had been conducted by staff members.

1.27 The selection of four areas in which to explore issues in more depth allowed for a higher number of interviewees than had been originally anticipated, through the assistance of the local statutory and voluntary addictions agencies described above. However the differences between the four areas in terms of programme delivery and the perceptions of staff and service users were not as distinct as might have been anticipated and there were more similarities in views and experiences than is sometimes the case with case studies. This means there is limited data from the case studies to suggest how local contextual issues might impact on programme delivery or experience. The differences that were identified have been highlighted in the report.

1.28 In some of the online survey questions for service providers it became clear with hindsight that some of the questions were more applicable to some service providers than others: some questions assumed a level of knowledge, for example about national policy and structures, that was not necessarily held and in these instances quite high numbers of respondents were unable to comment.

Ethical considerations

1.29 We set out in our original proposal for the work our sense that this research would not require a full NRES application or presentation at a formal NRES ethics board as it was likely it would come under the ethics assessment category of 'Service Evaluation or Service Audit' and because we had designed a methodology that would not require us to have direct access to patient identifiable information in the form of medical or case notes. The South of Scotland NHS Research Ethics Service confirmed in July 2013 that formal ethical approval was not required for the evaluation, but that we should write to each Health Board informing them of our work, which we did. We received confirmation in September 2013 that Caldicott approval was not required for the evaluation. The SPS Research Access and Ethics Committee also provided ethical approval. However, as a matter of good practice, we obtained written consent for all face to face interviews with service users and family members / carers.

Structure of the report

1.30 The remainder of the report is set out as follows:

• chapter 2 briefly describes the context for the service evaluation;
• chapter 3 sets out the main processes and structures in place to implement the programme locally;
• chapter 4 provides evidence on the effectiveness of the processes and structures;
• chapter 5 describes the impact of the programme;
• chapter 6 provides a synthesis of the findings with some observations for further discussion.