 Reliant on robust monitoring systems  Emphasis changed over time  Limited by data collection systems available  Data collection adapts to allow wider outcomes

 : Increase (doubling) in numbers treated, maximise contact, change behaviour esp. re injecting and HIV (public health led)  2007->: Effective treatment (retention for >= 3 months or treatment completion)  >: Successful completion (free of drug(s) of dependence) and non- representation to treatment

 : Increase (doubling) in numbers treated, maximise contact, change behaviour esp. re injecting and HIV (public health led)  2007->: Effective treatment (retention for >= 3 months or treatment completion)  >: Successful completion (free of drug(s) of dependence) and non- representation to treatment

 Retained 3 months  Treatment journey  Time since initial assessment  All treatment counted if gap <=21 days  Origin – DATOS?  One year follow-up  Sig. improvements (sustained at 1 yr)  Compared to reference category of < 3 months

 Tightened up in 2008/09  Treatment completed – Drug free  The client no longer requires structured drug treatment interventions and is judged by the clinician not to be using heroin (or any other opioids) or crack cocaine or any other illicit drug.  Treatment Completed - Occasional user (not heroin and crack)  The client no longer requires structured drug treatment interventions and is judged by the clinician not to be using heroin (or any other opioids) or crack cocaine. There is evidence of use of other illicit drug use but this is not judged to be problematic or to require treatment.

Retained 3 monthsSuccessfully completed % % 7% % 9% % 12% % 11% % 14% % 15% % 15%

 : Increase (doubling) in numbers treated, maximise contact, change behaviour esp. re injecting and HIV (public health led)  2007->: Effective treatment (retention for >= 3 months or treatment completion)  >: Successful completion (free of drug(s) of dependence) and non- representation to treatment; RECOVERY

 Nationally, PHI: only two drug specific  2.15 ‘successful completion of treatment (free of drugs of dependence)….non- representation to treatment within 6 months’  2.16 ‘People entering prison with a substance dependence issue who are previously not known to community treatment’

Out of treatment aHR= 1.72 [1.55, 1.92] Pre-publication, from Millar et al MRC-funded study

ProtectionTreatmentRecovery

TreatmentRecovery Recovery House Mortality Prison

 Payment for outcomes rather than treatment  Linked to recovery outputs  Number of outcomes  Completions & non-representations  Within treatment outcomes ▪ Abstinence, improvements in social functioning  External - offending, employment

 Dependence  Significant improvement/reliable change  Abstinence  Planned exit  Non-representation  Offending  Reduction in average offending  No ‘proven’ offending in 6/12 months

 Health and wellbeing  Cease injecting  Improve housing status  Hep B vaccination  Quality of life score (min 14)  Mortality  ‘Employment’  off benefits/paid work

 Offending  Convictions don’t measure all offending  Difficult to apply fair and robust tariff  Employment  Realistic expectation?  Dropped from outcomes in pilots  Mortality  ‘Low’ numbers for identifying significant changes

 Timeframes  Assessment & payments need to be aligned to months and financial years  Some outcomes don’t fit into this timeframe  Variation in rare measures too great to base payments on  Causality  Can treatment services realistically have impact?  Early results  Completions levels reduced in PbR areas?

 HEP C not given same status and HIV?  Reduced to local agenda?  Not core part of national targets so far

 Globally, drug use is an important, increasing, cause of preventable mortality: recent global estimates suggest that the years of life lost due to illicit drugs are greater than for alcohol 1  In the UK, deaths due to poisoning by illicit drugs are an important, and increasing, 2 preventable cause of premature mortality 3 and, in England and Wales, 3 account for the equivalent of 10% of all fatalities between years of age. 1 - Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012; 379(9810): 55– Murray CJ, Richards MA, Newton JN, et al. UK health performance: findings of the Global Burden of Disease Study Lancet 2013; 381(9871): 997– Bargagli AM, Hickman M, Davoli M, et al. Drug-related mortality and its impact on adult mortality in eight European countries. Eur J Public Health 2006; 16(2): 198– Office for National Statistics Statistical Bulletin. Deaths related to drug poisoning in England and Wales, (accessed: ).

 N = 207,275  Person years of follow-up = 571,646  Number of deaths = 4,048 CMR [95%CI], per 10,000 person years SMR [95% CI] All-cause71 [69 to 73]5.5 [5.4 to 5.7] DRP31 [30 to 33]- Avoidable mortality 58 [56 to 60]6.5 [6.2 to 6.7] Avoidable mortality excluding DRP 27 [25 to 28]3.4 [3.2 to 3.6]

Festival of Public Health 2013