SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

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New GP Contract & Drug Misuse

[Note: This article represents the personal views of Dr Clare Gerada, as of 16th May 2002, and may be subject to future updates.]

The New GP contract is a change from the current one in the following areas

  1. For the first time the work of a GP will be more strictly defined and costed.

  2. Essential or Core will be defined as self-limiting illness or the care of the terminally ill. All else is non-core and split into Additional and Enhanced Services.

  3. Additional Clinical services - these are essentially services such as management of Chronic disease, Imm and Vacs, Cervical Cytology, etc. It would be expected that a GP provides these services and unless told to the contrary will be paid for them. However, if a GP does not wish to, or can not provide them, then they can opt out - as long as they give three months notice of intent to do so. These services will then need to be provided by the PCT- maybe through another practice or through a community service.

  4. Both essential and additional will be financed centrally.

  5. Enhanced services - these can be nationally or Locally determined and in effect are the old 'local development schemes'. This is where drug services will no-doubt fit in.

  6. For completion - the new Contract will be with the GP Practice, not the GP individual. So it is upto a practice to provide services according to their own skill mix and need - rather than the dictates of the old staffing funding formula.

Implications for Drug Misuse

  1. GPs will not see as Core the management of drug misuse - it will not be defined as an acute self limiting illness, though we could argue that the management of...

    a) Complications of drug use;
    b) Acute Withdrawal;
    c) Immediate referral

    ...could be defined as such.

  2. Drug Misuse services will also not be defined under Additional Services - though I think this is where the old 'generalist working with shared care' should fit in. Ideally, GPs should be able to manage drug users with support - and that it should be seen as main stream unless the practice was in difficulty and opted out of this. Therefore - I would suggest that the DH and others try and negotiate that this is where the 'standard care' of drug users falls - including the provision of...

    a) Harm reduction.
    b) Drug prevention.
    c) Hepatitis B.
    d) Assessment and management of a few with support of shared care.
    e) Prescribing with support.

  3. I suspect that drugs will not fall into Additional category and instead will fall into the Enhanced.

  4. For Nationally agreed enhanced services they must be provided within a PCT - e.g. care of violent patients, minor operations, and for the Locally determined that they will be provided according to local need.

  5. In some situations - a locally defined enhanced can become a National enhanced service, for example (and this is my example), HIV services, or care for refugees if it is found that the service is needed more or less every where. Locally enhanced services will not be nationally priced - and will only be so once they become National. One could imagine that Drug misuse services would be negotiated under this category - that is Nationally Determined Enhanced Services, as this will ensure that all PCTs have to provide them, though I stress not every doctor or practice. The advantages of having drugs in this category are...

    a) Uniformity of payments;
    b) Uniformity of service level agreements;
    c) Uniformity of standards of care;
    d) More main stream - rather than 'an optional extra' according to the whims of the locality;
    e) Ensure the PCT provides the service;
    f) Chance that National Enhanced can become an Additional Service if it proved that the service really ought to be provided by eh majority of practices (who can still opt out though).

  6. All enhanced services will be funded through the Unified Budget - that is the HCSC and 'GMS' budget - hence the importance of ensuring that drugs fall into this category and are not seen as an optional extra. It maybe that areas of high need also have Locally Enhanced services around drug misuse or make a greater provision under the National Enhanced Scheme. It is proposed that there is a guaranteed floor to protect this money at local level and hence to have resources to develop services.

Gaps

  1. No mention of Prevention activity - where does this fit?
  2. No mention of chronic relapsing conditions such as alcohol.

Conclusion

  1. Contract will be voted in.
  2. The contract has opportunities for drug misuse - at best there will be competition for these patients, improved standards and service level agreements and more uniformity of care. At worse - it can leave the few committed or maverick doctors looking after large numbers - unsupported and untrained.
  3. The new contract gives more power to the PCT for defining and funding and commissioning services.
  4. Nurses have a greater role.
  5. Better use can be made of the GPsWI.

- Dr Clare Gerada, Hurley Clinic, Ebenezer House, London SE11 4HJ