Summary
This project comprised a model of care and pathway for hepatitis C blood-borne virus (BBV) within drug services in Bournemouth. The project introduced dry blood spot testing to be offered by drug workers within drug treatment services. Follow-up and coordination is provided by staff within the local services and, where appropriate, there is ongoing direct nurse to nurse referral into secondary care for assessment and treatment.
Prior to the service model being introduced just 68% of previous or current drug injectors in Bournemouth accessed drug rehabilitation services for hepatitis C. This has risen to 90% since the programme was introduced.
Challenge
In 2010/2011 Bournemouth had the highest rate of drug injectors in the South West of England, with an estimated 1,921 opiate and/or crack users, 897 of them injecting.
Bournemouth Drug and Alcohol Team (DAAT) described the provision of testing for Blood Bourne Virus (BBV) as ‘patchy’. Bournemouth was also missing national testing targets. BBV testing at this time was undertaken by the BBV team through venous blood samples. They then followed up those diagnosed with hepatitis C (HCV). This was not considered cost effective.
A new service model and pathway, Dry Blood Spot Testing (DBST), was introduced in June 2011. Drug workers now offer BBV DBST, with the BBV team following up HCV-diagnosed service users, who then follow the local referral pathway.
Objectives
The main objectives of the DBST initiative were threefold. Firstly, to increase the number of previous or current injectors accessing drug rehabilitation services being tested for HCV, by means of offering a test better suited to those with poor venous access. Secondly, to make better use of the BBV team’s time and resources. And finally, to introduce a clear pathway for nurse to nurse referral to secondary care for clients with chronic hepatitis C in need of assessment and treatment.
Solution
The service model and pathway was devised by DAAT, Bournemouth BBV Service and Dorset Viral Hepatitis Service. Training was provided locally for drug workers and the BBV team, and drug workers began offering BBV DBST when those most at risk of chronic hepatitis C accessed services.
Tests were carried out and, with client consent, the results registered on a shared database. Those at risk but testing negative were offered re-testing. Those testing positive were seen by the BBV team for post-test discussions and referral to secondary care. With client consent, positive results were also sent to GPs for their records.
The model and pathway has since been adopted by the West Dorset BBV service. It is being introduced in Poole and considered for use within Dorset Prisons.
Results
The proportion of previous or current injector service users being tested has risen from 68 per cent in October 2010 - March 2011 to 80 per cent in October 2013 - March 2014. West Dorset has seen a 21 per cent increase in testing in its first year.
Bournemouth is testing 90 per cent of its client group, compared with a national average of 73.9 per cent.
BBV staff are now free to take on more of a co-ordinating role. Tests have increased without loss of quality or the need for greater BBV service provision. BBV teams are now the main referrers into secondary care.
Learnings
There were concerns from the outset over the challenges DBST could pose for drug workers without a medical background. Training was therefore crucial.
An external training programme was bought. It had been devised specifically for drug workers, but those participating considered it too involved and lacking in focus. Drug workers undertaking the programme were left so lacking in confidence about the tests that they were not prepared to carry them out. The project therefore took longer than anticipated to become established.
This external training was replaced by a locally delivered internal programme, which continues to receive good feedback for appropriateness and content.
Evaluation
Regular audits have shown evidence-based data of the effectiveness of the initiative, while clients have reported that they appreciate BBV testing being offered by their drug workers. They feel that this demonstates that both workers and the service are interested in their overall health, not just focusing on their drug addiction issues.
Other feedback has shown that clients prefer DBST because it represents a less invasive test, particularly for those with poor venous access. Clients also benefit from direct referral to secondary care, with many admitting that they were unlikely to seek referral through their general practitioner.
