Review of methadone treatment in Australia

9 The roles of the public and private sectors

Page last updated: October 1995

As described previously in this report, the roles of the private and public sectors in the provision of methadone services vary considerably between States. To date, the private sector has been mostly involved in New South Wales, Victoria and Queensland. In the remaining States, health authorities are at various stages of promoting greater involvement by the private sector in the prescribing and dispensing of methadone.

9.1 Private sector prescribing
9.2 Private sector dispensing
9.3 Public sector participation
9.4 Preferred service delivery model
9.5 Summary
9.6 Recommendations

9.1 Private sector prescribing

In the three States where private programs are well established, the role of the private sector in prescribing methadone has variously evolved or been planned. The number of GPs and psychiatrists approved to prescribe methadone in all States as at June 1994 is shown in Table 14 below.

In both Queensland and Victoria, the participation of the private sector has been a deliberate policy which has encouraged medical practitioners to provide methadone services as an integral part of their normal practice. Thus the approach has been to have a large number of practitioners each providing services to a small number of clients. This is also the favoured strategy in those States seeking to expand the private sector's participation in methadone programs.

The advantages of this approach are that it:
  • integrates methadone services with locally available primary health care
  • avoids the stigma often associated with attending a methadone clinic
  • helps clients to avoid the "drug culture" often associated with methadone clinics
  • provides greater opportunity to extend services to areas without the infrastructure costs associated with establishing and operating larger clinics and
  • improves access to services.
The major problems associated with this strategy have been:
  • difficulties in attracting sufficient numbers of medical practitioners to meet the demand for services while keeping client numbers per doctor low
  • ensuring that medical practitioners are appropriately qualified and trained (both initially and on an ongoing basis) to provide a consistent quality of service and
  • identifying and monitoring the costs associated with services provided by the private sector.
The participation of GPs in the prescribing of methadone and the care of clients is widely regarded as pivotal to enabling the provision of such services to expand. Strategies are presented in this report which seek to reduce the problems associated with its wider application, while at the same time ensuring that the advantages of this approach are realised. The paucity of empirical data on the clinical effectiveness of this approach, and on the factors which affect practitioners' willingness to participate in methadone programs indicate the need for additional studies in these areas, and into ways in which the effectiveness of services can be maximised.
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In Victoria, the role of the private sector has also extended to the establishment of specialist methadone clinics in association with teaching hospitals, which provide services under contract to the Department of Health and Community Services (DH&CS). These clinics each provide 60 places for more difficult clients who require additional services to those offered by general practitioners. They also provide support and training services to general practitioners, counsellors and pharmacists. The clinics are funded under a contract with DH&CS.

The role of these specialist methadone clinics is seen as complementing rather than as an alternative to general practice based care. The relationship between the two service delivery mechanisms is illustrated in Table 15 below.

South Australia is following a similar approach in regard to the services to be provided by general practitioners and the public clinics. In general, GPs will provide services to clients who either wish to engage in formal efforts to reduce their unsanctioned opioid use but who have yet to demonstrate stable treatment progress (i.e. Stream B), or who have demonstrated good treatment progress and are stable (i.e. Stream C). Other clients (Stream A) will continue to be treated in public clinics using a low intervention approach.

Queensland has followed a similar approach to Victoria in the involvement of the private sector, although this has largely evolved as much as it has been planned. At the same time, the overwhelming number of private practitioners providing methadone services in Queensland are psychiatrists, while in other States, more GPs are involved. Part of the accreditation process for medical practitioners involves consideration of the number of hours worked by the doctor, and the limitations this places on the number of clients to whom the doctor is approved to provide methadone services. The view was expressed by several doctors (notably those working in public clinics) that the private sector tended to cater for the more stable clients, while the more difficult and unstable clients tended to be treated in the public clinics.

In NSW, the policy involving general practitioners has been pursued in part, while at the same time large private specialist clinics have been established and now provide services for a significant proportion of all methadone clients. Indeed, if these clinics were to cease to provide services for any reason, the public methadone service and remaining private practitioners involved in methadone services would be unable to cope with those clients currently treated at the clinics. In general, the private clinics cater for the same range of clients as their public counterparts, but may be restricted in the number of clients they treat.

Private practitioners in some areas of NSW also provide prescribing services through public clinics. This has been brought about by a lack of funds for visiting medical officers, together with difficulties in attracting medical officers to career drug and alcohol positions in public clinics. The private practitioners have not wanted to treat methadone clients in their own rooms, and have treated them at rooms provided by the public hospital for these consultations.

During the course of this review, the large majority of concerns and complaints raised concerning the provision of methadone services centred on the activities of some of the large private methadone clinics in NSW. The nature of these concerns included variable quality of service provision, high frequency of client consultation, a lack of counselling services, high charges to clients for the dispensing of methadone from the clinic, failure to observe the guidelines in regard to the availability of takeaways, and limited choice of dispenser of methadone for clients treated at the clinic. All of these concerns need to be addressed through a combination of quality assurance and accreditation processes, and through improved accountability procedures. These concerns have also been a major factor in other States not pursuing a strategy of large specialist private clinics.

Information provided by a sample of medical practitioners in New South Wales indicates considerable variation between GPs and psychiatrists in regard to the frequency of consultations, the approval of takeaway doses and the use of urinalysis for illicit drug usage among methadone clients. Data relating to these issues are presented in Section 10. The data reveal similar variations between specialist methadone clinics and methadone treatment services provided in wider practice settings. These differences may result from differences in client complexity between groups and the need for more frequent and intensive treatment among those clients being treated by psychiatrists. Given the considerable differences in costs incurred between these groups (see Section 10) there is clearly a need to monitor and evaluate the clinical effectiveness of different practice settings within the private sector. This issue is addressed further in Section 11.
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Table 14: Private medical practitioners approved to prescribe methadone, June 1994

StateGPsPsychiatristsOther 1Total
NSW
65
45
17
127
Victoria 2
n.a.
n.a.
n.a.
181
Queensland
7
17
-
24
SA
-
-
-
-
WA
-
-
-
-
Tasmania
9
-
-
9
ACT
-
-
-
-

1 Doctors who are not authorised methadone prescribers, but are approved on a one-off basis to treat individual clients - this usually occurs in the rural sector, and are generally GPs.
2 Dissection between GPs and psychiatrists not available for Victoria, but anecdotal evidence indicates that the large majority are GPs.

Table 15: The Victorian model for integrating primary care and specialist methadone services

TreatmentStage of case managementComponent of treatment - counsellingComponent of treatment - dispensingMedical services
Prior to referral
GP
GP
Community Pharmacy
GP
Following intake
SMS
SMS
SMS
SMS
Following early stabilisation
SMS
SMS
Community Pharmacy
SMS
Ongoing period of stability
GP
SMS
Community Pharmacy
GP
Returned to community
GP
GP
Community Pharmacy
GP

GP = General Practitioner; SMS = Specialist Methadone Service

9.2 Private sector dispensing

Dispensing of methadone through the private sector is a policy adopted in all States, to a greater or lesser extent. Information provided by the Pharmacy Guild of Australia on the number of community pharmacies involved in dispensing methadone in each State is presented in the table overleaf.

In all States except NSW, the use of community pharmacies is the dominant approach to dispensing. This approach allows clients to receive daily doses closer to their residence, and avoids the drug culture often associated with specialist methadone clinics (both public and private). (See Table 16)

In NSW, the community pharmacy approach is not considered to be feasible to cater for the number of clients under treatment, given the size of the program and the difficulties experienced to date in attracting pharmacists to the program. Approximately 66% of clients receive their doses from clinics or hospitals, a percentage which has been relatively stable for some years. Consequently, there is a continued need in NSW to rely on a range of outlets, including specialist methadone clinics (public and private) for the dispensing of methadone.

The NSW branch of the Guild together with the Central Sydney Area Health Service (CSAHS) have proposed a pilot project involving the CSAHS and community pharmacists aimed at providing a more integrated service between the public and private sectors. Clients will be assessed by a clinical team at the Royal Prince Alfred Hospital, and treated there initially. Once stable, suitable clients will be transferred to a community pharmacy for dosing. Ongoing treatment will be a cooperative arrangement between the public clinic and the community pharmacy. Clients will be charged the recommended Guild fee of $5 per dose, or a flat rate of $20 to $35 per week. Part of the project entails a $10 per week subsidy of these costs for half of the clients to assess the effect this factor has on client retention. If successful, it is intended to extend these arrangements to other locations.

One of the major issues raised during the course of this review was the inconsistency in charges for the dispensing of methadone in the private sector. While the above table provides an indication of the recommended Guild fee, many pharmacists charge different (and higher) fees than these. Further, in the large private methadone clinics in NSW, charges are as high as $7 to $10 per day. This is seen as being beyond the licit incomes of many clients, requiring them to turn to crime to support their continued involvement in the program, or to leave the program. This high cost has also been postulated as one of the main reasons for the diversion and sale of methadone. This issue is addressed further in the next section.

There is generally little empirical information available concerning the factors that influence community pharmacists in their decision to participate (or not participate) in methadone programs; the nature and extent of services they provide; the views of clients to the services provided in community pharmacy settings versus those provided in clinic-based pharmacies; or the effects of differential charges for methadone dispensing and administration. In this regard, there is a need for further studies and evaluation of each of these issues, in order to expand the participation of community pharmacies and to enhance the quality of services provided.
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Table 16: Community pharmacy participation in dispensing methadone, 1994

StateNo. of PharmaciesNo. of ClientsRecommended Fee/DoseTakeaways
NSW
300
1,900
$5.00
+$1
Victoria
215
2,300
$6.00
-
Queensland
145
1,904
$6.45
-
SA
250
793
$2.00-$2.50
-
WA
n.a.
300
$2.00-$5.00
-
Tasmania
23
33
$2.50
-
ACT
4
10
$5.00
+$1

9.3 Public sector participation

Historically, the public sector has been the major provider of methadone services throughout Australia. It is only in recent years that the private sector has assumed a greater role, due primarily to funding restrictions on State health authorities.

The role of the public sector in the direct provision of methadone services may be expected to continue to change in the future. If current trends in most States (particularly Victoria and SA) continue, public clinics (or those operated by the private sector under contract to State governments) will tend to specialise in the initial treatment of clients and the continued treatment of more difficult cases. Once stabilised, clients may be expected to be referred to the private sector.

While this apparent delineation of roles in the provision of services seems logical, one potential outcome that must be addressed is the effect on morale of staff working in the public clinics. Anecdotal information provided by public clinic staff in Queensland indicated that the continual treatment of complex cases, while challenging, can become demoralising over time. Treatment of more stable clients, who offer a greater chance of a successful outcome, is also needed to provide staff with a more balanced workload. Absolute delineation between the more difficult cases and stable cases between the public and private sectors may inhibit the extent to which this can be achieved.

Regardless of its role in the direct delivery of services, the public sector should continue to have an important role in the planning, regulation, co-ordination, quality assurance and monitoring of services. Elsewhere in this report, we have referred to the need to establish training, quality assurance and accreditation programs for clinics and service providers. These activities are appropriately handled through the public sector. Similarly, the regulatory processes pertaining to the approval of medical practitioners, pharmacists and clients are appropriate activities for the public sector.

In regard to service provision, as a greater proportion of services are delivered in the private sector through GPs and community pharmacies, there will be a need for improved co-ordination and support for service providers, and to ensure that clients' rights are protected. It is in this capacity that the public sector has the potential to expand its current activities. The need for improved communication between prescribers and dispensers, client liaison and provider support may be expected to increase. Mechanisms need to be established to ensure that continuity and quality of services are maintained across service settings. It is in this area that public services may be used to provide a valued role. The pilot project proposed by the CSAHS and the NSW branch of the Guild is indicative of the approach being developed to support this process.
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9.4 Preferred service delivery model

In seeking to identify a service delivery model best suited to the Australian setting, we are conscious of the different approaches that currently exist across jurisdictions throughout Australia. The roles of the public and private sectors, psychiatrists and GP's, and of specialist clinics versus wider practice settings vary considerably, and in combination tend to confuse the different service models in use.

Given the complexity of the existing environment, we consider that a preferred service delivery model should be based primarily on matching individual clients' needs with the services provided by suitably qualified and experienced practitioners. The sector and clinical settings in which those services are provided should be subordinate to these criteria.

Our discussions with practitioners and administrators involved in the delivery of services has indicated that clients may be broadly classified into two groups:
  • clients who, having entered a methadone program, are relatively stable and require low levels of intervention and counselling and
  • clients who, having entered a methadone program, are relatively unstable in their response to treatment and require higher levels of intervention and counselling.
We recognise that clients in the first group may at different times face crises and require additional support. Under such circumstances, these clients may require access to practitioners with skills additional to those required during periods of greater stability. The service delivery model therefore needs to be sufficiently flexible to cater for these occasions. Nevertheless, in general terms, the service delivery model should be based upon the needs of these two groups of clients.

The service needs of the stable group of clients may be seen as representing the baseline of methadone services which all approved service providers must be capable of providing. The guidelines for methadone services used in most jurisdictions reflect the service regimen for these clients. We have previously suggested (in Section 8) that all practitioners should receive a basic level of training to qualify them to provide these services, and that these skills be maintained through ongoing education and training. This approach aims to ensure that practitioners providing services to this group of clients meet the minimum training standards required, while at the same time seeks to minimise any barriers to their participation. Typically we envisage this role being undertaken primarily by GPs as part of their wider practice. This approach reflects the models being developed in Victoria and South Australia, and brings with it the advantages previously outlined in Section 9.1.

For this group of clients, the dispensing of methadone may be expected to be undertaken primarily by community pharmacies, which is consistent with the concept of "mainstreaming" methadone services. In the absence of a willing community pharmacy, local hospitals or clinics may provide this service. Given that dispensing represents the most frequent component of methadone services, it necessarily carries with it an expectation that the dispenser will assume an important role in observing and monitoring the client's condition on a regular basis. It is essential therefore that the dispenser be adequately trained in this area, and that close liaison be maintained between the dispenser and the medical practitioner. We have previously referred to the role that the public sector may take in facilitating this liaison and co-ordination.

Experience in the application of this model overseas has shown that clients tend to remain in treatment for longer durations, and are less likely to withdraw from methadone treatment than a more interventional approach. This may have implications for the overall cost of services in the longer term.

For more complex cases, service provision would be restricted to practitioners with higher levels of qualifications and experience. The nature of the qualifications and experience required would need to be determined and agreed to by the relevant professional educational bodies, but could be expected to be in the form of post-graduate qualifications in the area of drug and alcohol treatment. Services are expected to comprise higher levels of intervention, client support and counselling than are provided for stable clients. There is a natural tendency for these services to provided in specialist clinic settings, but need not necessarily be restricted to this environment. Such clinics may operate in either the public or private sectors.
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We suggest that clients in need of this level of service would be referred to suitably qualified practitioners in the same way that other patients requiring specialist services are referred to appropriate specialists in other disciplines. This approach is therefore consistent with current medical practice, and provides a mechanism whereby clients with more complex needs are "filtered" through to practitioners with the skills commensurate with their treatment needs.

In regard to the dispensing of methadone to this group of clients, the need for closer client monitoring suggests that this activity is best undertaken in the same clinical setting as the practitioner. Given that this is most likely to be in a specialist clinic, there is a greater likelihood that staff with the appropriate qualifications and experience will be available. This would also be consistent with our proposals in regard to the quality assurance and accreditation of clinics.

This service delivery model may lead to a natural division of roles between the public and private sectors, due primarily to the fact that the majority of practitioners with formal qualifications in the area of drug and alcohol treatment have traditionally tended to work in the public sector. However, the approach in Victoria to contract for such services with the private sector demonstrates that this is not an inevitable outcome of this model.

The application of this model on a widespread basis necessarily requires a mix of service providers to cater for the needs of the different client types. The limited number of suitably qualified practitioners to cater for more complex cases may restrict capacity to cater for these clients at a local level, and require referral to specialist services located further afield. However, this limitation applies equally to other service delivery models. There will be a need for the development of appropriate mechanisms for complex cases in remote areas to have access to appropriately qualified practitioners to treat them. This model, however, provides for greater access to suitably qualified practitioners for clients who have achieved a level of stability in their lives, and provides them with a greater opportunity to function more normally in their domestic environment.

In order to be effected, however, the payment system used to remunerate practitioners providing different levels of service for different groups of clients needs to support models of best practice, and be attractive to practitioners. Discussion of alternative funding models is presented in Section 12.

While this model is consistent with the approaches already being developed in South Australia and Victoria, and may find acceptance for defining the role of the private sector in other States, its application in New South Wales may be restricted by the large number of clients participating in methadone programs in that State. The current service delivery model in NSW relies heavily on large private clinics to cater for a significant proportion of these clients. It is questionable as to whether sufficient GPs and community pharmacists would be willing to participate in methadone programs, or that the public sector has the capacity to cater for these clients in the short term. Under these circumstances, it is likely that the large private clinics will continue to provide services to both stable and complex cases. There will be a need for further consultations with the NSW Health Department to assess the likely implications of this situation for the delivery of methadone services in NSW.

In implementing this model, a number of specific strategies will need to be pursued and investigated. These include:
  • Developing and agreeing on the different training and experience requirements of medical practitioners to treat stable and complex cases
  • Developing agreed clinical criteria for the identification and referral of complex cases to specialist providers
  • Establishing mechanisms for the treatment of complex cases in remote areas or where access to specialist services is limited and
  • Assessing the overall applicability of the proposed model in those states, particularly New South Wales, where the proposed approach represents a significant change to the existing service delivery models and structures currently in place in the private sector.
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9.5 Summary

The roles of the public and private sectors in the provision of methadone services have changed dramatically over the past five years, and are expected to continue to change in the future. The role of each sector varies considerably between States and has either evolved through history or been the result of deliberate policy initiatives. The main trend today is to involve GPs and community pharmacies in methadone services as part of their wider practices. This approach seeks to use the existing service infrastructure of the private sector, rather than establish a new public infrastructure with its associated costs. NSW also has the situation where large private methadone clinics have been established, mainly as a result of funding shortages in the public sector which were unable to meet the increasing demand for services.

Clearly, the involvement of GPs and community pharmacies in methadone services has the greatest potential to improve access to services by clients, particularly in more remote areas, and to reduce the stigma associated with attendance at specialist methadone clinics. The major difficulty with this approach has been, and continues to be, attracting medical practitioners and pharmacists to participate in methadone programs, and the need to ensure that they are appropriately qualified and trained. There is a need to collect further information about the factors that influence participation in the provision of methadone services, and on client views about the services provided in different practice settings.

In the current situation, where there is a mix of private and public participation in various forms in the provision of methadone services, it is clear that there is no "one best way" for future services delivery. While some of the large private clinics in NSW have drawn considerable and apparently justified criticism in regard to the quality and costs of services they provide, they nevertheless meet a current demand for services. There is clearly a need to address the concerns raised about the activities of a number of these clinics.

Notwithstanding a reduced reliance on the public sector for direct service provision, there is a need for this sector to extend its current activities in the administration, regulation, quality control, coordination and monitoring of services. At the same time, support services for the private sector must be established to encourage their participation and to ensure that client needs are appropriately addressed. These activities will be essential if service quality and continuity are to be improved and maintained.

We have outlined a preferred service delivery model which seeks to match the needs of different groups of clients with the services provided by suitably qualified and experienced practitioners. This approach does not restrict the public and private sectors to defined roles, although the tendency for more highly qualified practitioners in the field of alcohol and drug services to be located in the public sector may lead to a natural division of roles. The model seeks to provide greater access to methadone services for clients when they are stable, while providing the necessary safety net for them in times of need. At the same time, the needs of more complex cases are catered for by practitioners most qualified to meet these needs. The referral system proposed in this model for complex cases is consistent with current medical practice across specialties.

In implementing this model, a number of specific strategies will need to be pursued and investigated, particularly relating to the training and experience required of practitioners treating complex cases, and the clinical criteria for the identification and referral of such cases. At the same time, mechanisms for the treatment of clients in remote areas under this model, and its applicability across all jurisdictions need to be considered.

The mix of public and private service delivery cannot be considered without consideration of the funding mechanisms used. Private sector participation is synonymous in the current funding environment with Commonwealth funding through Medicare. The extent to which these services continue to expand to meet growing demand and to improve access to services results in a greater proportion of methadone treatment costs being borne by the Commonwealth. The costs incurred by States and the Commonwealth in the provision of methadone services are addressed further in the following section.
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9.6 Recommendations

  1. That the involvement of general practitioners and community pharmacists in the provision of methadone services be encouraged as an appropriate method for meeting the demand for and improving access to services.

  2. That a study be undertaken into the process of dispensing and administering methadone; the factors influencing community pharmacist participation; the views of clients regarding community versus clinic-based dispensing arrangements; and the effects of differential client contributions.

  3. That State health authorities extend their activities in co-ordinating services between public and private service providers, and in providing support services to the private sector.

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