Network No 26 (May 2009)
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Mike Webb and Gordon Morse describe how they weaved their way through the legislation to provide an innovative service which trains injecting drug users, the people most likely to witness a drugs overdose, to administer naloxone. Those trained were also given naloxone to be used in the event of their witnessing an overdose. This is an excellent example of how service users have worked together with service providers and commissioners to make important changes to drug treatment.
There is an increased emphasis on clinical governance in drug treatment services. Susi Harris takes us through what this means in practice for primary care based services.
With the heightened profile of the problems associated with alcohol misuse in the UK, Ian Gilmore discusses the important role general practice can play in improving health services for alcohol users.
As he retires, Stefan Janikiewicz reflects upon his work with drug users and how this has been one of the most interesting facets in his career as a doctor. SMMGP feel that drug services will never be the same once he hangs up his stethoscope!
Martin Weatherhead guides us through the complex area of legislation and good practice regarding safeguarding children.
Martin Weatherhead is Dr Fixit to a GP seeking advice regarding safeguarding children.
A clinical governance lead asks Dr Fixit, Susi Harris, for guidance regarding implementing clinical governance in primary care drug treatment.
See all the latest events on the Bulletin Board.
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We are excited to publish this edition of Network to coincide with the 14th National Conference of the Royal College of General Practitioners Working with Drug and Alcohol Users in Primary Care in Liverpool. The theme of this year's event is Family medicine: from cradle to grave and for those of you not lucky enough to be here, we are giving you a flavour of the conference by publishing articles from keynote speakers.
For our front-page article we are excited to publish Pete McDermott's views on both the pros and the cons of the increasing emphasis on recovery in the UK drug treatment field, and the importance of looking at every service user as an individual, rather than prescribing what is best treatment for them. We are also pleased to publish Ian Gilmore's article (Alcohol - The Poor Relation: What Can We Do in General Practice?) on the crucial role that primary care can play in developing and improving alcohol services to meet the increasing demands that are being placed upon health services. Martin Weatherhead tackles the complex issue of how to look after the needs of the children of drug users, both in his article (Safeguarding: The Essentials) and in his Dr Fixit response (Dr Fixit's Advice - Safeguarding Children), offering excellent practical advice on one of the most challenging areas of work for both clinician and the patient. And don't miss Charles Cornford's article Encouraging general practitioners to treat drug users: an analysis of the policy of "shared care" on our website soon.
Last, but not least, we are delighted to celebrate Stefan Janikiewicz's distinguished career in the drug treatment field and his colourful approach to life in his article (Pensioner Wants Drug Baron Job). SMMGP feel he has played a large part in improving services both locally and nationally, and would like to thank him for the support he has given to our project; he will be sorely missed when he retires.
Finally don't forget to apply for SMMGP's 4th Annual Conference which will be held in Barnsley on 9th October 2009! For more details see our Courses & Events section.
The topic of recovery has had a large amount of coverage lately and SMMGP believe it is important to look at the evidence on this subject, and also to allow people to define their own path to recovery. The line between supporting and forcing an individual's recovery can be a fine one. Here is Peter McDermott's history and view of recovery and what works for him. Ed.
"Today then, Recovery with a capital R is the flavour of the month and you can't attend a meeting without somebody sharing their latest plans to encourage the growth of recovery in their area."
During the early 80's, cocaine use exploded in the USA - particularly among the white middle classes. Initially, it tended to take the form of recreational use of powder cocaine, but as time went on, there was a huge growth in freebasing and crack cocaine use, which resulted in a much darker, much more problematic pattern of use.
By the mid-to-late 80's then, being "in recovery" was almost like a fashion statement in US media and entertainment circles. Just like Captain Frank Furillo, the leading man in the dominant US TV drama of the era Hill Street Blues, actors, writers, producers and directors would all attend a meeting before going to work, and the rooms of Alcoholics Anonymous, Narcotics Anonymous (NA) and Cocaine Anonymous became the kind of place where a high flyer could pick up a hot Hollywood starlet or New York fashion model.
Recovery was "in".
Here in the UK, not so much. Firstly, the respectable middle classes hadn't yet embraced cocaine use in the way they did in the USA. And in the small circles that did, it tended to be the much less problematic use of snorting powder cocaine. Aside from a couple of meetings in London, 12 step groups tended to be dominated by alcoholics and in the case of NA, by heroin addicts. The fellowship lacked that trendy zeitgeist that it had managed to capture in the USA.
Nevertheless, as time went on and increasing numbers of people managed to attain sobriety through the help of the fellowships, the concept of recovery began to grow, and it was given an even bigger boost last year, when the UK Drug Policy Commission decided to follow the Betty Ford clinic by producing its consensus statement on Recovery (with a capital "R").
Today then, Recovery with a capital R is the flavour of the month and you can't attend a meeting without somebody sharing their latest plans to encourage the growth of recovery in their area - so is this a good thing, or is it a bad thing?
To my mind, it's both.
Until the beginning of this decade, drug treatment in the UK had been pretty poor. I don't think anyone can seriously argue with that proposition. Check out the Audit Commission reports into the state of drug treatment in the UK before you take it up with me. Although there were patches of excellence, by and large, services operated on the basis of personal prejudice rather than any evidence base, and there were many, many services where what they were providing was hurting rather than helping.
"And so just as I know that we've often been unhelpful in holding some people back when they really wanted and were ready to move on, similarly, we've been just as unhelpful in pushing some people into moving on before they were ready to do so - often with disastrous consequences for the person concerned."
What people lacked was a vision. Too many services seemed incapable of providing their users with any kind of faith that change, for them, might be possible. Too many were content to allow their clients to wallow in a midden of methadone, wine and welfare, without offering any realistic or practical programme for change. Too few workers possessed the sort of skills that enabled them to encourage, to inspire, to have faith in the possibility that change was actually possible.
But I think that is finally starting to change and I think it's changing for a number of reasons.
As the number of people who've experienced problems with their drug use grows, so too, will the number of people who have managed to overcome those problems. We've got a large population of people who are now "ex-users", some of whom have overcome their problems with the help of drug treatment, and some have managed to avoid treatment altogether. Many of these people are now working in the drug treatment industry.
We've also seen a very substantial growth in the number of people who attend 12 step fellowships, and those people tend to think and speak the pure and uncut language and concepts of the US recovery movement as there's a great deal of cross pollination between the US and the UK arms, as people here listen to tapes of US speakers, or attend meetings where US speakers will share experiences. And a lot of these people are working in the treatment industry too.
We're becoming much better at motivating people, at sharing our own experiences of addiction and recovery, at showing people that change really is possible.
But if you remember, I said there was a downside to this current emphasis on recovery. The downside, in my opinion, is this: The British drug treatment field is peculiarly prone to fashion and trends, and we have the historical memory of a goldfish. Last week it's methadone maintenance, and so we're doling it out by the bucketful. This week it's contingency management, so everybody is queuing up for their five pounds gift voucher. Next week, it's recovery, and if we aren't careful, we'll be hiring teams of outreach workers to provide a free taxi service to take people to meetings.
What we sometimes seem to be incapable of recognising is the fact that treatment needs to be individualised, and directed at meeting the needs of the patient and where he or she is in their drug-using career.
And so just as I know that we've often been unhelpful in holding some people back when they really wanted and were ready to move on, similarly, we've been just as unhelpful in pushing some people into moving on before they were ready to do so - often with disastrous consequences for the person concerned.
Just last night, I was interviewing a woman in her mid thirties who was telling me the story of her recovery. This woman has dual diagnosis and suffers from bipolar disorder, but she has been drug free for the last four years - including free of psychiatric medications. She uses yoga and meditation to manage her bipolar disorder, which enables her to recognise when her symptoms may be reoccurring and allows her to seek medical help as it's needed.
When she first entered treatment, about fifteen years ago, she was a chronic and compulsive injector of street heroin which she was using to manage the symptoms of her depression. Her keyworker successfully advocated with the community drug team to get her a script for 100mg methadone ampoules, and she managed to gain a degree of stability that she'd never had prior to that. For the first time in many years, she wasn't using street drugs, she had a nice flat, money in the bank, she was taking holidays. She was engaged in the process of recovery. Then her key worker left the service, and was replaced by somebody who felt that methadone ampoules have no place in drug treatment. She was being reduced by 5 mg a week - far too fast, according to her - and when she reached 20mg, she relapsed and started using street heroin again.
In order to pay for her drugs, she began sleeping with her dealer, and began using crack cocaine. Within a year, she was homeless, completely chaotic, had a criminal record - something she'd avoided until that point - and a crack habit. Her life was completely derailed and her psychiatric illness was completely out of control.
My friend is an attractive, intelligent, articulate woman who is often asked to speak about her experience of recovery, and so I asked her, "When people ask you to tell your story, do you ever tell them the part about how services actually made you worse?" Of course, she doesn't. People like to hear about a positive outcome and a happy ending. They don't want to hear about the stories of the people whose lives were made worse by the treatment services.
"And for other people - people like me - recovery is a process that may also involve the ongoing use of substitute medication. But that shouldn't stop anybody thinking of us as any less useful, any less valuable, or any less deserving of all of those other goals that people who are drug free require in order to ensure that their recovery is as robust and as secure as we can possibly make it"
"For two years, my life was stable and they took that away from me just because some clinic's policy changed", she says. "At that time in my life, I needed my hit every day."
I'm also a long-term patient in drug treatment. Like my friend, I've also experienced mental health problems, but have enjoyed long-term stability that I attribute primarily to the fact that I'm prescribed methadone ampoules and they work very well for me. I've made several attempts at achieving abstinence, all because I've wanted to change, none of which have been fruitful. I'm my own toughest critic, and the last thing I need in my life is a fresh young drug worker nagging me about how I need to be moving on.
So, what is recovery? For me, recovery is about making the best out of your life - achieving the best possible outcome you can hope for in terms of the quality of your life.
For some people, that will mean abstaining from all drug use. Those people need to be supported and helped to the best of our ability to achieve their goals. Not only to become drug free, but also to be helped with the process of reintegration into full citizenship, into becoming a useful and productive member of society.
And for other people - people like me - recovery is a process that may also involve the ongoing use of substitute medication. But that shouldn't stop anybody thinking of us as any less useful, any less valuable, or any less deserving of all of those other goals that people who are drug free require in order to ensure that their recovery is as robust and as secure as we can possibly make it. And though many struggle to acknowledge the fact, addiction is a chronic and relapsing condition. Some of those people who currently define their recovery in relation to abstinence may, in the future, find that that is an option that no longer works for them, and come to rely on substitute prescribing once more. The commonalities between the two communities - the abstinence based group and the medication based group - are greater than the things that separate us.
Perhaps one day, we'll even begin to recognise that fact?
Mick Webb and Gordon Morse describe how they weaved their way through the legislation to provide an innovative service which trains injecting drug users, the people most likely to witness a drugs overdose, to administer naloxone. Those trained were also given naloxone to be used in the event of their witnessing an overdose. This is an excellent example of how service users have worked together with service providers and commissioners to make important changes to drug treatment. Ed.
"In 2007 there was recorded a total of 2702 drug related deaths of which 1154 were attributed to either heroin/morphine or methadone"
- Office of National Statistics 28/8/2008
Service users' voice - such a powerful entity, especially when there is unity and the will to attain a common goal. It does not take a rocket scientist to work out that the most effective individuals to intervene with an overdose situation are those most likely to witness them firsthand - or to work out that those with years of injecting drug use may just know how to inject a drug. Naloxone training and supply would appear to be a sensible and very logical step to reduce the overdose fatalities in the UK.
Paramedics and staff in accident and emergency departments in the UK and Europe have been using naloxone for decades to bring people back from the brink of oblivion. The administration of naloxone by service users is not a new intervention and the Chicago Recovery Alliance and projects in New York have been doing this for years. Do we really need to be spending time looking for evidence that naloxone works, or looking for evidence that injecting drug users can inject drugs?
When setting up our project we drew on the work of The Maudsley Institute and the National Addictions Centre (NAC) who had been pioneering take home doses of naloxone (Ref 1), and it was from this work and model that Simon Joseph from the Bristol Specialist Drugs Service, a data collection point for the NAC pilots, willingly passed on his expertise, delivering training to myself and other service users to be able to administer naloxone, train trainers, and start the project off. It became a multi-agency pilot, working in partnership with service users, the ambulance service, the British Heart Foundation (who came in voluntarily to provide the Heart Start CPR training to the Drug Rehabilitation Requirement cohort), the police, the Drug and Alcohol Action Team (DAAT), a GP and a clinical nurse. Originally the project was the remit of the Harm Reduction Strategic Group, part of the DAAT structure. It went on to develop into an independently funded task group, working with, but not being part of the DAAT.
The absolute driving force was the service users' voice. The Wiltshire DAAT actively supported service users to be independent and to lead the project. It was a very exciting time.
Another milestone was reached when the unified voice from the South West Users Forum made itself heard during a regional meeting with service user representatives from 16 DAAT regions. They all wanted the work of the pilot to happen in their areas. This voice has been recently amplified with unanimous consensus at the National 2009 service users Voices for Choices conference in Birmingham. The show of hands from 600 delegates of service users demonstrated a powerful and concise statement from the service users' voice of the UK.
In Wiltshire the pilot had 6 months to train and supply with a 400 microgram minijet of naloxone to 50 people highly likely to witness an overdose. The aims of the project were to reduce drug related deaths, to increase clients' awareness of transmission of routes of blood borne viruses and to encourage testing for blood borne viruses. The implementation of the strategy relied solely on street work. We aimed to become part of existing street/dealer networks in order to develop trust, and to supply a drug within these networks that saves lives.
From April to September 2007, operating from our base in Trowbridge we trained and supplied injecting drug users with naloxone. Through developing links with street networks, and accessing "behind closed doors" drug using groups we began to hear that injecting drug users were interested in the pilot, and we started to be invited into "privileged access" drug using environments. Everyone we came into contact with expressed warmth and support, and a great deal of enthusiasm for the project. Bath Area Drugs Advisory Service (BADAS), one of the providers operating satellite needle exchanges, were happy for us to train and supply naloxone at its needle exchange. At the busiest period, we were delivering back to back training and supplying this life saving drug from this venue.
A key emphasis in the training was to, in the event of an overdose, always call the ambulance service first and foremost. Naloxone can buy some time, and in a rural situation such as Wiltshire, this could make the difference between life and death, so easy communications with acute services was paramount. This was demonstrated when a service user witnessing an overdose was able to take advice, via speakerphone, from the emergency call operator whilst she was administering naloxone.
The ambulance service worked with us to develop a protocol, which all call handlers, dispatchers and ambulance crews were made aware of, to recognise the trigger word " naloxone" in emergency calls so the crews knew that it may have already been administered.
During the 6 month pilot naloxone was used 3 times. Twice was with a homeless man living in a tent in an isolated area of Trowbridge. The ambulance service came to the evaluation of the project and publicly acknowledged that this intervention, with one service user helping another, had saved a life.
The care pathway for debriefing after use of naloxone for both the administrator and patient served as an opportunity to share experiences, off-load a little, record data, and gather some comments.
"I haven't used since Thursday, I never realised my motivation for change would come from this direction. The Ambulance service said I had saved his life!" - Hayley
Hayley receiving acknowledgements from Steve Balckmore, Operations Manager Great Western Ambulance Service based in Chippenham Wiltshire
"I don't know why, but I feel different..." - client comment after training.
Naloxone is an incredibly safe chemical. It does not change into anything else over time, is an opioid antagonist and is treatment specific. It can only do one thing; it reverses the effect of an opiate overdose. It is also a Prescription Only Medicine (POM). This classification in itself could be the biggest stumbling block in preventing naloxone to be rolled out nationally. This could have significant impact on reducing drug related deaths, and reducing the unimaginable trauma that families and loved ones have to cope with when a family member or friend dies through overdose.
The benefits highlighted in this pilot, and the changes in service users' lives who took part were profound. Not only nearly 50 people trained and supplied with naloxone, trained in CPR and overdose recognition and response, and lives saved, it became a platform for delivering vital harm reduction information around polydrug use, highlighting routes of BBV transmission, building confidence and self belief, and became a tool for informing chaotic drug users, unaware of what treatment services have to offer on how to effectively access needle exchanges, outreach workers, and structured treatment.
The professionals' fears of "what happens to us if something goes wrong?" were unfounded, and it was a great example of service user involvement galvanising harm reduction.
Without the service users of Wiltshire, this project would never have happened. The spirit and enthusiasm demonstrated in this pilot, so difficult to record in the target-led environment we work in, has already made a difference to the county of Wiltshire, and it is our hope, that a little of it will rub off elsewhere.
A Doctor's View
Byzantine prescribing regulations need to be negotiated to effectively introduce its use.
To begin with, any prescription medicine should only be used by the person to whom it is prescribed; clearly in the case of naloxone, anyone with a serious opiate overdose will be in no fit state to self administer a dose of naloxone and so to be of benefit, it should be administered by someone to whom it is prescribed, to someone to whom it is not prescribed. Fortunately there is a "get out" clause in this case as naloxone is allowed to "be given by anyone for the purposes of saving a life", but it is still a very grey area legally to deliberately prescribe naloxone with that ultimate intention.
The second difficulty is the issuing of an injectable drug without the prescriber or his deputy (under a Patient Group Directive) actually administering it. When a drug is "personally administered", the NHS prescription fee is waived - but if the preparation is handed over intact for use at a later date, then it attracts the standard dispensing fee. Some of our clients are exempted from prescription charges as they are on benefits - but nonetheless each prescription has to be endorsed exempt on the back after evidence of exemption has been provided - which is pretty impractical.
In the case of this pilot, the commissioners went to a dispensing GP and a creative solution was found to these problems; the GP purchased the naloxone through his own dispensary and supplied doses to clients on a named private prescription basis where no money changed hands, and the cost of the drug was reimbursed to the dispensing GP by the commissioners. Indeed no profit or fee was raised by anyone taking part in this pilot.
There are two points of potential concern however. The first is that at the time of the pilot, the naloxone minijet did not have an integral needle and long needles had to be supplied separately. It was felt that these needles might have been attractive to groin injectors who might have misappropriated them, leaving the naloxone minijet needle-less and useless. The second was that access to naloxone might encourage greater risk taking: it was felt that clients might take greater risks with amounts and combinations of drugs, knowing that naloxone was available if the experiment went wrong. These issues cannot be prevented, but we would recommend that anyone seeking to emulate such a programme address this in their education - although drugs education has been shown to sometimes have exactly the opposite effect.
It is a great pity that a widespread roll-out of naloxone is inhibited by inappropriate regulations: naloxone is an extremely safe drug, and there is a very good case for having it supplied by pharmacists at needle exchanges and through outreach programmes such as we have described. It seems to be an unusual case of lives being recklessly endangered by the law. There is still potential for confusion around the legal aspects and possibilities of potential minefields, and a lot of "creative interpretation" is needed.
1. Strang J, Darke S, Hall W, Farrell M, Ali R. 2006 Heroin overdose: the case for take-home naloxone? BMJ. ;312:1435.
There is an increased emphasis on clinical governance in drug treatment services. Susi Harris takes us through what this means in practice for primary care based services. For more on clinical governance, see Dr Fixit's Advice - Clinical Governance. Ed.
You can't escape it - clinical governance (CG) is everywhere - it takes up the whole of chapter 2 of the 2007 Clinical Guidelines (Ref 1), and National Treatment Agency (NTA) performance management has focussed on it for a couple of years now, asking Drug and Alcohol Action Teams (DAATs)/partnerships to set up and audit their clinical governance arrangements. Many clinical staff, including doctors, nurses, and pharmacists, now have a professional duty to undertake clinical governance under the terms of their professional body registration. This article is about how CG, the provision of an environment where high quality care can flourish, and the detailed review of all aspects of care to ensure it meets standards for safety and effectiveness, will affect drug treatment in primary care. (if you still don't feel sure what clinical governance is, rather than redefining it here, I would suggest you have a look at the 2007 Clinical Guidelines or the forthcoming NTA publication on the subject).
Mental Health Trusts, and several of the larger non-statutory treatment providers have been implementing fully-fledged CG processes for some time. For some of the other secondary care providers, many of the elements of CG already exist, and devising a CG standards framework and processes for assurance are simply a matter of pulling them all together in a systematic way. Primary care too, of course, is in the business of providing safe effective care for drug misuse, but there are particular challenges for primary care drug treatment in implementing systematic clinical governance. To start with, drug treatment provision is just one small part of a very wide remit for primary care trusts (PCTs) and GPs, and in a constantly changing political environment, it has to compete for attention with a myriad other priorities like heart disease, cancer, care of the elderly and so on. Clinical governance is a forever commitment; it has to be embedded into the everyday business of caring for people, and doesn't lend itself well to flavour-of-the-month-ism.
Secondly, for primary care, drug treatment is a far more nebulous beast than for other provider organisations - in fact it is a little difficult to see it as an organisation at all. It is more like a loose network of GPs and practices, providing care in a wide range of styles, from the individual GP seeing and prescribing for one or two of his/her own patients with minimal support, to practices running large schemes under a variety of contractual arrangements, perhaps treating patients registered at other practices, and/or even employing its own staff. Any clinical governance process has got to be proportionate to the level of the care provided or it is in danger of being top-heavy, or conversely, ineffective.
"Clinical governance is a forever commitment; it has to be embedded into the everyday business of caring for people, and doesn't lend itself well to flavour-of-themonth- ism"
Thirdly there is a suggestion (I'll duck just after I've said this!) that PCTs and GPs have been a bit, shall we say, inconsistent with implementing clinical governance. The NTA guidance says: "There are indications that commissioning for clinical governance has been poorly developed in PCTs across the board (CGST and NatPaCT, 2003 (Ref 2)) and there may be particular issues with regard to independent providers including primary care (NAO, 2007 (Ref 3))". PCTs actually have a duty in law to commission care that complies with Standards for Better Health (Ref 4) and to have mechanisms in place to monitor compliance. That means service level agreements such as Locally Enhanced Services should include CG requirements and PCT CG departments should require information about the outcome of CG reviews, but they may need to be reminded of this when it comes to drug treatment (Ref 5).
But don't let this gloomy picture discourage you too much: there are areas where CG is alive and well in primary care drug treatment; it is perfectly possible to meet this challenge, of which we have proved ourselves capable so many times. So where does one start? The NTA has made two key recommendations to help kick start the process:
- Every provider should have a clinical governance lead.
- Every DAAT/Partnership should have a multidisciplinary forum with a remit to implement CG.
"For primary care, drug treatment is a far more nebulous beast than for other provider organisations - in fact it is a little difficult to see it as an organisation at all. It is more like a loose network of GPs and practices, providing care in a wide range of styles"
Designation of a clinical governance lead in every practice is pretty much universal now. But general practitioners may be under the impression that CG for any drug treatment provided by their practice is being taken care of by somebody else. They need to be made aware of whatever arrangements are in place (if any) and ask for support if this is needed. In particular they can point to the key domains that the practice should be looking at when it wants to assure the quality of its drug treatment, and because they will probably be familiar with the PCT CG framework and processes, they can help to ensure that the practice's CG activity is framed in the same "language". In practice, this will usually have meant that the CG activity is based on the 2003 Standards for Better Health, with its seven domains of safety, effectiveness, governance, patient focus, accessibility, care environment and public health (Ref 6). This will make it easier for individual practices to demonstrate quality of their drug treatment to the PCT that commissions them. They may also act as a valuable resource for the practical aspects of CG such as clinical audit and significant event analysis. Having a clinical governance lead, however, does not mean they can "do" all the CG for you. As the NHS Clinical Governance Support Team has said "clinical governance is everyone's business" and in many cases, it is actually a requirement of one's professional registration. This can include requirements to:
- adhere to good practice guidelines and protocols;
- maintain skills and knowledge through continuing professional development;
- report serious untoward incidents (SUIs) and participate in SUI reviews;
- participate in clinical audit.
Note that some staff may be voluntarily registered with a professional organisation - such as the Federation of Drug and Alcohol Professionals (FDAP) - that also requires them to adhere to codes of conduct for safe and effective practice.
The idea of a multidisciplinary forum, with its group approach to Clinical Governance is well served by Shared Care Monitoring Groups (SCMGs). These were originally set up under the terms of a 2000 DoH memorandum which allocated a non-recurrent £20K to each health authority to set up a SCMG. Their main purpose was to prevent drug related deaths, and they were to undertake this in a very broad way, setting up shared care schemes to bring prescribing GPs (some of whom were quite isolated, and were well-meaningly prescribing for drug misuse in quite idiosyncratic but inadvertently dangerous ways) under the umbrella of partnership with local community drugs teams, and agreed guidelines for safety. SCMG would also oversee establishment of new pharmacist services: supervised consumption schemes to prevent diversion of prescribed medication, and needle exchange to reduce blood-borne virus transmission. Many SCMGs ran primary care training and conducted prescribing audits, but once they had established a cadre of practitioners, and a template for good practice, were wound up after a few years feeling that that their original remit had been fulfilled. However, the NTA is keen to see them revitalised or refreshed to become local drug treatment clinical governance groups, and to extend their focus beyond primary care GPs and pharmacists, to include all service providers. These "New SCMGs" or DAAT Clinical Governance Groups will be tasked to take a partnershipwide view and:
- agree local "who does what" guidelines for treatment, including psychosocial interventions and prescribing (note that there is a wealth of new guidance on evidencebased clinical practice (Ref 7), and on safe handling of medicines);
- establish care pathways between providers and address any gaps in provision;
- ensure mechanisms for workforce development such as training, peer support networks, appraisal and supervision;
- set up a framework of standards for all aspects of care;
- conduct processes to assess quality of care, such as clinical audit, significant event analysis and service user feedback;
- review provision against the standards framework systematically.
It's important to note that all these activities need resourcing in terms of time, money and skills, and DAATs/partnerships may need to be reminded of this when establishing the new remit for SCMGs.
From individual primary care practitioners and teams through to the new multidisciplinary groups, the idea of all this activity is to produce and demonstrate high quality safe effective services for our patients - hopefully this article demonstrates how clinical governance for drug treatment can be as achievable in primary care as for any other type of service.
1. Department of Health (2007) Drug Misuse and Dependence - Guidelines on Clinical Management
2. Clinical Governance Support Team and National Primary and Care Trust (2003) The Strategic Leadership of Clinical Governance in PCTs: A Learning Resource for the Members of PCT Boards and PECs. Leicester: ClinicalGovernance Support Team
3. National Audit Office (2007) Improving Quality and Safety, Progress in implementing Clinical Governance in Primary Care: Lessons for the new Primary Care Trusts. London: National Audit Office.
4. Department of Health (2004) Standards for Better Health
5. "A significant number of PCTs had failed, hitherto, to recognise that their clinical governance duties and responsibilities extend to those services that they commission, as well as services they provide." (Modernisation Agency, 2004)
6. Though the new Care Quality Commission (CQC) (which is formed from a merger of the Healthcare Commission (HCC) and Commission for Social Care Inspection (CSCI)) has recently launched a new 4-domain framework.
7. Including: Drug Misuse and Dependence: UK Guidelines for Clinical Management, and the suite of NICE technology appraisals and clinical guidelines on drug misuse
With the heightened profile of the problems associated with alcohol misuse in the UK, Ian Gilmore discusses the important role general practice can play in improving health services for alcohol users. Ed.
It would be hard to argue that there is no attention paid to alcohol misuse these days - our daily newspapers and television programmes are saturated with horror stories of binge drinking and its consequences - and we should perhaps be grateful for this. Until 2001 the consequences of alcohol misuse were passed over virtually completely and our Chief Medical Officer (CMO) Sir Liam Donaldson should take some credit for pointing out in his Annual Report of 2001 (Ref 1) that deaths from liver cirrhosis had risen almost tenfold in the previous 30 years. Around the same time the Royal College of Physicians published a report "Alcohol - can the NHS afford it?" (Ref 2), the answer to which was a resounding "No". But still the emphasis in the media is on crime and antisocial behaviour. This is probably mirroring the stance of our politicians, both Gordon Brown and his predecessor Tony Blair, referring to a small minority spoiling it for the vast majority of responsible drinkers.
It is much easier to demonise those making trouble on our streets on Saturday nights than to confront the uncomfortable fact that many millions of people (30% in some age-groups) are drinking well above safe recommended limits. In England, the National Audit Office estimated that 18 per cent of the adult population (7.6 million) are drinking at "hazardous" levels; another seven per cent (2.9 million) are showing evidence of harm to their own physical and mental health, including approximately 1.1 million people who have a level of alcohol addiction (dependency). Furthermore the biggest trend is to home consumption. Even those drunk in the city centres have probably consumed most of that alcohol from off-licence purchases of heavily discounted drink - so called "front-loading".
"It is much easier to demonise those making trouble on our streets on Saturday nights than to confront the uncomfortable fact that many millions of people (30% in some age-groups) are drinking well above safe recommended limits."
So the time is right to turn the spotlight from antisocial behaviour to the health consequences of alcohol misuse - both acute and chronic. As alcohol-related hospital admissions rise by about 80,000 each year and are set to pass 1 million per annum within a few years, the case is strong. We know that the best indicator of alcohol-related health harm is our per capita consumption and the most important drivers of this are price and availability. The Chancellor put an above inflation, but modest, increase on alcohol duty last year, but this does not seem to have been passed on by the supermarkets. Our Chief Medical Officer for England has made a welcome return to the topic by calling for a minimum unit price for alcohol of 50 pence in his recently published 2008 Annual Report (Ref 3). While this was promptly dismissed by the Prime Minister (see earlier comments about not wanting to punish the vast majority of sensible drinkers because of a small minority), there is little doubt that this will stimulate debate and make action more likely in the future. It looks as if the sequence of events will be like the ban on smoking in public places - a call for action by the CMO for England combined with early and innovative action in the devolved nations (with Scotland leading the way) will pave the way for subsequent action in England. The same is likely to apply to access, with Scotland again leading the way. Already north of the border, alcohol can be displayed only in certain restricted areas in supermarkets, and public health is a factor that has to be take into consideration when licenses are granted or renewed.
"The time is right to turn the spotlight from antisocial behaviour to the health consequences of alcohol misuse - both acute and chronic. As alcohol-related hospital admissions rise by about 80,000 each year and are set to pass 1 million per annum within a few years, the case is strong."
But there are important actions that can be taken in addition to the above public health measures, particularly in the areas of early detection and treatment. Here general practice is well placed to take a lead. The opportunities for giving advice to those drinking hazardously or already harmfully have been well-rehearsed and brief advice in the context of primary care (previously called brief interventions) has been shown to produce significant and sustained changes in behaviour for those not already severely dependent. Such advice can be delivered by other staff as well as medical practitioners. We have to somehow incentivise better uptake of early detection and brief advice in the primary care setting, as it is hugely cost-effective.
General practitioners also are crucial in helping patients with alcohol dependence access appropriate specialist care. Sadly there is a dearth of well-developed specialist treatment centres in many parts of the country. Although more costly than brief advice, these services are again highly costeffective, particularly if they prevent progression to end-stage complications. Clearly GPs are not in a position to deliver these specialised services themselves but can be real advocates in their health community for making them available. Where I have seen "joined-up" care for patients with alcohol problems, GPs have been vital in stimulating commissioners to invest in this area. The models of care and the evidence underpinning them are well worked out, but new investment has not been included in the work of the National Treatment Agency and the Drug and Alcohol Action teams.
"Where I have seen "joined-up" care for patients with alcohol problems, GPs have been vital in stimulating commissioners to invest in this area."
Within PCTs' management structure, it is often not clear who is responsible for planning and commissioning particular alcohol services. Those PCTs who do commission services for alcohol misuse frequently do not monitor the results that such services deliver. The National Audit Office reported that almost a third (30 per cent) of PCTs reported that they did not manage the performance of the alcohol services they commission within primary care, such as identification and brief advice. It is little wonder that progress has been slow. At least there is now a requirement for PCTs to report alcoholrelated hospital admissions but the target is to slow down the increase rather than reverse it. But the data are improving. Local Alcohol Profiles for England (LAPE) measure alcohol misuse in each of 150 local authority areas in England using 23 separate indicators, including, for example, months of life lost due to alcohol misuse, alcohol-related violent crimes and rates of binge drinking (Ref 4). The indicators are based on national data sources such as the Hospital Episode Statistics produced by the NHS and mortality data produced by the Office for National Statistics (ONS), with an estimation factor for each local area applied where appropriate. The resulting profiles compare each authority's ratings to the national average and highlight indicators which are significantly better or significantly worse than average. These profiles are prepared by the North West Public Health Observatory (NWPHO), based at John Moore's University in Liverpool, and will become an increasingly important tool in holding primary care trusts to account.
There has never been a better time to make a difference in the field of alcohol-related health harm. The evidence for what works is available, there is a tide of public opinion behind increasing action and all UK governments have alcohol harm reduction high on their strategies. The medical profession can take the initiative and make it happen.
2. Royal College of Physicians Working Party Report (2001) Alcohol - can the NHS afford it? Royal College of Physicians: London
As he retires, Stefan Janikiewicz reflects upon his work with drug users and how this has been one of the most interesting facets in his career as a doctor. SMMGP feel that drug services will never be the same once he hangs up his stethoscope! Ed.
Unusually I do not actually have any British blood in me ...not a lot of people know that. However, I have always liked the systems that British people invent and by which they operate. By that I do not mean that British systems are any better or worse than for instance, Scottish systems. The fundamental quality of all men (and women) being your equal and that no-one is better than you, and also that no-one is worse than you, is the way that we should all live our lives. I think the British system of drug treatment has been as good as it gets with or without the evidence base!
"My mother had been a nun who was sentenced to death in Moscow and this was commuted to hard labour in Siberia. It was unlikely that any of my parents' three children would fall into the category of 'normal'!"
Now that I have taken my pension and have got my senior rail card, it is enjoyable to reminisce. I was born to Polish parents who settled in the West of Scotland after meeting in Iraq during the war. My mother had been a nun who was sentenced to death in Moscow and this was commuted to hard labour in Siberia. It was unlikely that any of my parents' three children would fall into the category of "normal"! They settled in the west of Scotland where my father became a consultant physician. Our small village of Mauchline was the place that Robert Burns (our National Bard) married, lived in for many years and fornicated with many of his neighbours. He also found time to write poetry. It is always important to have a bit of culture! I was brought up a Polish Catholic and imbued with the ideology of looking after those that may be less fortunate than oneself, and this fitted in with the west of Scotland philosophy as well. All three children applied for medicine and were accepted. There was little choice in those days.
I do remember that alcohol has always caused havoc in Scotland and judging by international statistics we are still dreadful north of the border with ethanol misuse problems. It seems that Eastern European countries may be worse but that does not help my genetic history. Alcohol misuse has been, and still is, the most fascinating but complex and deadly condition and disease. I have been dealing with substance misuse for the last 35 years, starting with work in the Southern General Hospital in Glasgow. Yes, one did have to boil up one's glass syringe and also the large needles that went into diamorphine prescriptions in those early days. I cannot believe that the prescribing clinicians or the fascinatingly exotic patients would have believed that now we give out disposable syringes (that are colour coded) and needles ...and containers ...and citric ...and filters ...and even sometimes the diamorphine that necessitated the need for all the paraphernalia. Chemical misuse problems have always been interesting, challenging, demanding and eventually most satisfying. I have never really perceived it as being work in the true sense. "Hobby" makes it sound as if it is not real work and in many ways my fundamental thinking is based on caring, kindness, fairness and instilling boundaries in situations that other people deem complex.
Apart from the university of life and being given an honorary diploma (the Royal College of General Practitioners must have realised I would not pass the exam) I have no formal qualifications for substance misuse. When I started in general practice on the Wirral I was a prescriber of diconal and Palfium. Methadone use took over but we were still a long way from observed consumption. It was about this time that benzodiazepines, especially in the form of temazepam capsules, were hitting the prescribing scene. Nothing could be as bad as the disadvantages of barbiturates (never forget that Elvis Presley's post mortem showed 5 different types of barbiturate in his system!). Life has so many ironic and amusing twists and temazepam capsules came near the top of the list for causing their own particular form of havoc. I actually do not do that much, never have done. I have a very strong team around me on the Wirral and my managers have always understood my shortcomings. From my admin staff to my specialist keyworkers, and everyone who works with me I have largely found them enormously supportive. This also applies to the old style health authorities through to the modern primary care trusts and acute and mental health trusts.
At one crazy time, I was Clinical Director for Drugs on the Wirral, Chester and Crewe - and then alcohol was added to the list. I have always thought of myself as being a general practitioner with a lot of simple and straightforward thoughts about chemical misuse. I have always revelled much more in seeing patients than attending meetings. Nowadays, I believe I have a slight attention deficit at meetings and have a very low boredom threshold. This often results in me saying things that I know after consideration that I should have left unsaid, as it did not help people nor the situation. For me, seeing people with drug and alcohol problems has always been much more fascinating than someone with asthma or diabetes or ischemic heart disease or hyperlipidaemia or other chronic relapsing conditions. Mental health difficulties have inspired my empathy (maybe I have too much insight). Phraseology of dual diagnosis does seem superfluous as I always believe that primary care should deal with 95% plus of mental health difficulties.
"For me, seeing people with drug and alcohol problems has always been much more fascinating than someone with asthma or diabetes or ischemic heart disease or hyperlipidaemia or other chronic relapsing conditions."
When I started as Clinic Director on the Wirral, I had the most wonderful mentor and psychiatrist from Manchester called Tim Garvey. He said I could always phone him at home, and on one occasion I did so. It was to check what he thought of the Manchester United Team prior to them playing Liverpool. He is a wonderfully gentle man with great common sense and remarkable insight into my somewhat unusual ways. My best and funniest times were with David Young, my co Clinical Director for a few years. It is little wonder that he moved on. I do not think it is easy to work with me for more than a few years! Our Benedictine background still makes us laugh uproariously about things that other people would not find amusing.
I do not think I am an acquired taste, I just think it is quite difficult to work with me because I know I am somewhat irascible, often moody, and place too high a demand on people who work with me. On the other hand I have been blessed with energy.
This weekend I finished work on Friday evening, did a talk at a national meeting on Viral Hepatitis in Bristol, ran the Liverpool half marathon and then dug at our allotment in the afternoon. If I have a medical regret, I just wish I were not on warfarin for the rest of my life. I am reminded to have my INRs when I have haematuria. My wife is the opposite to me and is infinitely patient and communicates with other people in a special way. We are proud of our magnificently dysfunctional family of 8 children. My GP partners have done their best to support me as I disappear to attend meetings now and again. I think I have actually had a problem over the years with anything that comes under the auspices of "authority", especially when matters are not explained well to me.
We came into drug misuse as GPs at a time when we were a cheap commodity. Nowadays the North West drug meetings are co-chaired by primary care and psychiatry. There does not seem to be any animosity or competitiveness amongst us. I believe that the new generation of psychiatrists coming through may well be the less expensive option and may well take over the national drug misuse units. Who cares, as long as it is done proficiently? I would like to see myself as leaving work in a few years time with this country "baron" of drugs. This is what made me think of the title of this article but I know it is much more likely to be the opposite and I think that the alcohol difficulties will be even worse. So far I have had a great journey and I even thought that the drug tsar was good and that the National Treatment Agency is great. Standing up for what you believe in is paramount.
Martin Weatherhead guides us through the complex area of legislation and good practice regarding safeguarding. children. For more on safeguarding children, see Dr Fixit's Advice - Safeguarding Children. Ed.
Whilst the decisions we have to make to safeguard children are often difficult the principles underpinning that decision making process are simple. If you identify something which you feel places a child at risk it is your responsibility to make an appropriate response to safeguard that child.
It is a large and complex subject and this is the briefest of summaries. Everyone needs to be aware of the available guidance and how to use it. The Royal College of General Practitioners Toolkit (Ref 1) is a good starting point and offers the opportunity to self-assess your current practice. Whilst I may stress some of the salient issues in this article it doesn't mean others are less important.
We are probably all aware of the concept of child protection, i.e. protecting those children who are suffering, or are at risk of suffering significant harm, be that abuse or neglect. Significant harm is the threshold that justifies compulsory intervention in family life in the best interests of children. Abuse may be physical, emotional or sexual. Scotland also has an additional category, non-organic failure to thrive. Neglect is the persistent failure to meet the child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development.
When a child is in need of protection you have to refer to Children's Services (the social workers) and this has to be done in accordance with your local LSCB (Local Safeguarding Children Board) procedures which should be available to everyone working directly, or indirectly, with children. If this threshold of concern is reached you don't have to have parental consent to make the referral. However you should seek consent if possible, unless you feel it would place either the child or yourself at increased risk by doing so (and this would include if you were concerned about Fabricated and Induced Illness, previously known as Munchausen's by proxy). The referral must be made in accordance with your local procedures and is often known as a Section 47 referral in England, Wales, and Northern Ireland (Ref 2).
Safeguarding is a more inclusive term and suggests a broader focus. It has two elements:
- protecting children from maltreatment;
- preventing impairment of children's health or development.
This broader remit includes looking for the hidden harm outlined in the 2003 report of the same name (Ref 3). The children of problematic drug users (and it is important to recognise the problematic part of that description) are more likely to experience a range of adverse life experiences and the greatest impact we can have on the lives of these children is not to ignore them and to provide high quality substance misuse treatment for their parents.
"Whilst the decisions we have to make to safeguard children are often difficult the principles underpinning that decision making process are simple. If you identify something which you feel places a child at risk it is your responsibility to make an appropriate response to safeguard that child."
If you identify safeguarding issues and you feel the child requires extra support to address those concerns, but you don't feel the threshold has been reached to make a Section 47 referral then you have to have parental consent to make that referral. This is known as a Section 17 referral in England, Wales and Northern Ireland or Child in Need. The issue of consent tends to polarise discussion groups and stimulate contention but this is a useful rule of thumb to help you decide whether you need to seek consent.
We all have responsibilities but those responsibilities are not to decide in isolation whether a child is being abused or not. We contribute to that process but the agency with lead responsibility is the local authority via Children's Services. The approach is often likened to a jigsaw with different agencies (health visitors, mid-wives, school nurses, GPs, teachers, social workers, housing workers, drug workers etc) all contributing vital information, vital pieces of the jigsaw, to allow the whole picture to emerge. This is co-ordinated by a social worker if the threshold to make a referral under either Section has been met. The CAF (Common Assessment Framework) (Ref 4) will be increasingly used in future when agencies need to share information but where thresholds haven't been met to trigger a referral to Children's Services.
It is appropriate to seek advice from a senior colleague if you are uncertain about whether you should make a referral or how to make that referral. This may be from a safeguarding team/child protection team within a health trust, from one of the Named or Designated Professionals, the consultant paediatrician on call, the designated practice lead or from your line manager. The duty social worker within Children's Services may also offer advice. It is important to remember that telephone advice from a social worker to make a referral is not the same as actually making that referral. You have to follow your local procedures. You need to make a formal enquiry to the Custodian of the Child Protection Plan, make a verbal referral to the duty social worker and then follow that up with a written referral.
"The children of problematic drug users (and it is important to recognise the problematic part of that description) are more likely to experience a range of adverse life experiences and the greatest impact we can have on the lives of these children is not to ignore them and to provide high quality substance misuse treatment for their parents."
The social worker makes an initial assessment following any referral and will collate available information. The decision about the next step is theirs. They may decide to proceed to a Section 47 enquiry and arrange a child protection conference. They may decide to take no further action or make a specific recommendation for the provision of a service which they feel addresses the concerns that have been raised. You should be informed in writing of their decision.
If a case conference is called you have a duty to contribute. If you are unable to attend you must send a report, although best practice is to do both. As it is part of a Section 47 enquiry consent is not a requirement (although as above it is good practice to seek it if appropriate) before you share confidential information. This includes parental information you may hold which has an impact on the child's safety. It also includes the positive and protective factors you are aware of such as drug treatment success. We must also remember not to "stereotype families or adults who do have health problems such as substance misuse although it is crucial that a holistic approach is taken with families so that the needs of children are assessed when treating patients with addictions" (Ref 1).
It is crucial that if you do not agree with the outcome of your referral that you raise that objection. Again you must follow the LSCB guidance on this.
Lord Laming, in his report into the death of Victoria Climbie (Ref 5), made a comparison between how medical staff respond to two different potentially fatal conditions: children with possible cancer and those in need of protection. We wouldn't just ring a paediatrician for advice if we thought a child had cancer. We would write a letter and chase-up the outcome of the referral. Sadly Victoria's death was just one in a long line of well-publicised child deaths. Baby P is the latest. Unfortunately the lessons we learn are largely lessons we are re-learning as the same ones tend to echo across the generations. Our roles as GPs have been less scrutinised in the past but this is now changing. Lord Laming made no comment to the claim of an inner city London GP that he had no experience of child protection in his report but the GP in the baby P case has already been suspended. The recommendations in the Progress Report6 have already been accepted by the Government and are explicit. It is the "statutory duty of all GP providers to comply with child protection legislation and to ensure that all individual GPs have the necessary skills and training to carry out their duty" (rec 34) (Ref 6). In addition "all drug and alcohol services should have well understood referral processes which prioritise the protection and well-being of children" (Ref 6). These should include automatic referral where domestic violence or drug or alcohol misuse may put a child at risk of abuse or neglect.
"Unfortunately the lessons we learn are largely lessons we are re-learning as the same ones tend to echo across the generations. Our roles as GPs have been less scrutinised in the past but this is now changing."
I have been involved in a number of reviews into the deaths of children (Serious Case Reviews, previously known as Part 8 Reviews) in Sunderland over the years. Some of the recommendations are fairly predictable and many have been made elsewhere previously. We have to record information and communicate better between professionals and between agencies. We need to be able to recognise the signs and symptoms of abuse, such as bruising in non-mobile babies. As doctors we need to thoroughly examine children, particularly for unusual symptoms. We have to remember and consider the impact of parental behaviour on children and that includes paternal behaviour such as substance misuse, poor anger control and domestic violence. We have to remember neglectful parents don't always act on our recommendations and take their sick children to hospital appointments or admission wards.
If we don't think about safeguarding we don't look for problems, and if we don't look we don't find them, and children's suffering will continue to be overlooked until it's too late.
2. The Children Act (1989) England, Wales and Northern Ireland. In Scotland the Children (Scotland) Act 1995 applies.
3. Advisory Council on the Misuse of drugs (2003) Hidden Harm: responding to the needs of the children of drug users
6. The Protection of Children in England: a Progress Report (2009) Lord Laming
Martin Weatherhead is Dr Fixit to a GP seeking advice regarding safeguarding and the child of one of her patients. Ed.
Dear Dr Fixit,
I am a GP and have been working with Sarah for 6 months now and she had become fairly stable on 60mls methadone - until recently she was using heroin once a week. She is a single parent and has a 5 year old daughter. She would use heroin only when her daughter was at her mother's house. However, in the last few weeks she seems to be less stable and has been using crack cocaine and benzodiazepines as well as heroin, and she has missed her last 2 appointments with me, which is unlike her. I am becoming worried about both her own health and also how she is able to care for her daughter at the moment, but do not want to break down the trust we have built up. Can you help?
This is where simple principles become complicated by the complex reality of practice. There is often no single correct answer and our decisions are affected by nuances. I've been involved in many discussions where different Named Professionals make different judgement calls.
From the outset I would advise you to seek advice from one of the Named Professionals. I'm assuming you'll optimise her treatment, and I'm assuming that you were happy that there were no safeguarding concerns before her recent deterioration. In itself this is a fairly contentious assumption and would stimulate debate. For instance are you sure her grandmother's is an appropriate place for the child to stay? Does her grandmother also use drugs? Do you know if other professionals have been involved, and if a Common Assessment Framework (CAF) been carried out for the child?
If her daughter was under 5 you would have the benefit of a joint discussion with the professional in the primary health care team who tends to have the greatest safeguarding expertise: the health visitor. Unfortunately you don't, although you could contact the school nurse to see if there are any concerns at school. They see her daughter regularly and will be able to let her know whether she is attending regularly, and answer questions about her health, appearance and general well being. You can also make an enquiry to the Custodian of the Child Protection Plan (previously known as an enquiry to the Child Protection Register) to see if other concerns have been raised recently. The CAF and Contact Point are new developments that are not fully implemented yet in many areas but may become the first point of call in the future for information gathering.
An obvious protective factor is that Sarah's mother already provides support and care. A further one is that Sarah has previously had a period of stability in treatment during which you seem to have developed a good therapeutic relationship. The context in which you became aware of her instability is also important. Did she voluntarily disclose it in an attempt to address her problems or was it a concealed problem that became clinically apparent during review? Are other agencies involved in her treatment and is her deterioration apparent to them?
Under these circumstances I would do a home visit before I made a referral to Children's Services. I wouldn't delay the visit and would reconsider immediate referral if I was unable to review my patients quickly. Once I had reviewed them I would discuss with Sarah whether she required any extra support for her daughter whilst her drug use was unstable. I would encourage her to see that the support offered by Children's Services is available to ensure she is able to continue looking after her child herself, and that it was not a punitive referral. I would reiterate that I had had no concerns about her parenting previously and anticipated her making a full recovery. I would also seek her consent to involve her mother more closely in looking after her child until she was stable. There may be specialist workers in your area who work with the children of drug users and if there were I would also suggest that her child could be referred to them. If she consented I would make a referral to Children's Services. If she didn't and I was concerned that she was unable to provide adequate care for her child I would explain that I had no option other than to refer her daughter as a Child in Need of Protection, without her consent, as I have a duty to prioritise the child's needs. That is my paramount concern. Over the years I have made many referrals and these have almost all been with consent. I have maintained a good relationship with all of those patients and their parents.
If she didn't consent and, given my knowledge of the family over years, the result of my other enquiries and the positive outcome of my visit I was satisfied that the child was not in need of protection, I may defer that referral. However you must record the process by which you made your decision. The decision is also not one that you can make and then forget about. You need to constantly review Sarah's progress towards the treatment goals you have jointly set and reconsider a referral if circumstances deteriorate or fail to improve.
This is a difficult decision but we must not forget that a referral without consent may prevent Sarah from disclosing illicit drug use on top of her script in future and may therefore paradoxically increase the future risk of harm to her daughter.
A clinical governance lead asks Dr Fixit, Susi Harris, for guidance regarding implementing clinical governance in primary care drug treatment. Ed.
Dear Dr Fixit,
I am the PCT lead for clinical governance and I wonder if I could ask your help on a clinical governance issue concerning controlled drug prescribing which is outside of my area of expertise? The shared care coordinator is concerned that one of the GPs on the scheme is prescribing outside the locally agreed guidelines. The GP has been practicing for 3 years and is in a partnership of two. The other doctor does not treat drug users. She has passed Part 1 and Part 2 of the RCGP Certificate in Management of Drug Misuse and attends regular local training. The coordinator is concerned because the GP is prescribing methadone tablets to about 4 patients and methadone injectables to 3 others, neither of which are allowed in the local guidelines. She manages 20 drug-using patients in total. How should I proceed?
Thanks for sharing your problem with us, this is a really classic situation which underlines how useful good clinical governance arrangements can be.
There are really two problems here. The first, and the most pressing is to do with the current care. Clearly the prescribing you have described is outside of routine practice as advised by national, as well as local, clinical guidelines but it is important to remember that a doctor that is competent and confident to do so may appropriately prescribe outside guidelines, as long as they can justify their actions and there is clear documentation for the reasons for their decisions in the patient notes.
It is important to get a full assessment from the shared care coordinator as to the exact details of the prescribing. Did this doctor take over these patients when they were on these medications or did she start them as new prescriptions? What are the grounds for prescribing tablets and injectables? Has she taken advice from a specialist in coming to these decisions, and has this prescribing been agreed with the care coordinator/keyworker as part of a care plan? What safeguards are in place to prevent or assure the absence of risky use (such as injection of tablets, or accidental overdose) or diversion of medication? When you have as much information as possible there are then two immediate questions
- "Is this prescribing appropriate?"
- "Is this doctor competent?"
Because of your expertise you will know that these are the same questions you would ask about any prescribing issues, but as it is not your clinical area, I would suggest the role of determining these two questions should fall to the most senior substance misuse physician in your partnership, and/or your Regional RCGP Substance Misuse Lead. They may well know this GP and they may be able to add further information to the clinical picture. Their first act should then be to assess the risk to patients. The lead pharmacist and/or the accountable officer for controlled drugs should also be asked for information that may help to complete the picture.
If risks are high (for instance, if large quantities were being dispensed at a time to an unstable patient, or if the patients were dependent on other depressant drugs, particularly benzodiazepines and antidepressants or alcohol which might increase the risks of accidental OD), then you may need to take urgent action in order to obtain an alteration to the prescribing. There will need to be a face-to-face meeting with the doctor to explain the concerns and to offer support and supervision around safe prescribing. Most often these issues can be dealt with at this point but if the problem cannot be resolved at that more informal level, PCT underperformance processes can be activated.
The second issue is one of assuring the safety and effectiveness of prescribing across the partnership. Why has this come to light after the doctor has been in the scheme for 3 years? Could it happen again? All the prescribers need to have appropriate training, supervision, and appraisal for the substance misuse part of their work in its own right. They need to be part of a scheme that means they avoid working in isolation, and truly share care with local specialists. Annual audit of shared care prescribing should be being undertaken as part of good practice.
As she is a GP, ultimately responsibility for ensuring clinical governance will fall to the PCT as commissioner, but partnerships should take responsibility for ensuring that the PCT recognises their statutory duty for quality for drug treatment provision and takes action. More than this, the partnership needs to be proactive in developing a process for comprehensive clinical governance review, to help ensure that no other potential disasters waiting to happen are lurking in the wings. The NTA is due to publish clinical governance guidance, which clarifies the roles and responsibilities in clinical governance. You may find it helpful to refer to the draft document.
(Note that the published version will have been altered in the light of the public consultation in 2008, but broad principles of clinical governance remain unchanged).
In particular the NTA advises partnerships to undertake two key actions. Firstly they should ensure a person is nominated to lead on clinical governance on their behalf. This person should champion clinical governance for all the treatment providers in the partnership area, and link closely with PCT clinical governance processes. Secondly, partnerships should ensure a multidisciplinary clinical governance forum exists in their area, Many partnerships have found that their local Shared Care Monitoring Groups are ideal for this purpose, though they may need to be reactivated or have their terms of reference refreshed. The group should agree a clinical governance framework and undertake systematic and comprehensive review of performance of all parts of the local treatment system against the framework, using not only routine data that is collected for other purposes, but also clinical audit, and take action to resolve issues identified. An audit of prescribing, in this instance, could have picked this issue up earlier, and reviewing supervision and appraisal arrangements to ensure they are embedded in the framework, could have identified a gap to be addressed. These actions illustrate the proactive approach of good clinical governance. Treatment providers, by and large, work in good faith to deliver the best possible care to their patients in response to needs, but occasionally in their willingness to help they may lose sight of the wider picture. By engaging in clinical governance processes, they can ensure their treatment is safe and effective.
4th National Primary Care Development Conference: Partnerships in Progress - Working Together
Improving joint working with primary, secondary, 3rd sector and others - Ensuring positive policy in primary care based drug treatment services
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RCGP Certificate in the Management of Drug Misuse in Primary Care Part 1
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RCGP Substance Misuse Unit Presents: Update on Primary Care & Substance Misuse - Moving Up to the Next Level
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SMMGP works in partnership with The Royal College of General Practitioners (RCGP) and the National Treatment Agency for Substance Misuse (NTA).
Network ISSN 1476-6302.