GP Business: Drug Misuse Management
Two levels of training are helping GPs to improve drug services, reports Lucie Benson.
With substance misuse featuring in the national enhanced services section of the new GMS contract, it is a good time for GPs to consider their involvement in this aspect of practice and the training available.
GPs have the opportunity to assess how drug treatment services would impact on day-to-day practice and how they can contribute further to giving drug users the most appropriate care and support.
In many areas, there has been a significant increase of shared-care systems and multi-agency initiatives bringing GPs, pharmacists, nurses, social workers and other healthcare professionals together with specialist services to achieve a growth in treatment capacity and a reduction in waiting times.
Yet further expansion of treatment services is vital if more problematic drug users are to gain access to treatment and it is precisely here that GPs can make a difference.
This can be achieved through specialist training. The main way to go about this is to complete the RCGP 'Certificate in the Management of Drug Misuse', which was launched in 2001.
Dr Jenny Keen, clinical director at the primary care clinic for drug dependency in Sheffield, says that the certificate has made a huge impact on GPs wanting to develop their skills to help drug misusers effectively.
'The certificate is aimed at people with some experience, who are going to be GPs with a special interest (GPSI), and who want to learn the evidence base, develop their skills and look at areas where they feel they need to improve,' she explains.
'About 700 GPs, plus practice nurses, pharmacists and prison doctors have been on the course so far.'
'Many of those are GPs who were already treating drug users, but the course has enabled them to develop so that they feel they are more competent in this area, or able to take on more people,' adds Dr Keen. Dr Keen thinks the training has many advantages for GPSIs. 'Once a GP has been on the course they are able to help people in the practice who have not been on it but who still want to help drug users,' she says.
'The GPSI is able to support them, as well as support other local GPs in other practices and people have started up networks and groups. It has really got things going and has made a tremendous difference.' Another advantage to the course, says Dr Keen, is that it allows GPs to feel more qualified to manage drug misusers.'
'The main reason for GPs not working with drug users has always been lack of training, because there has never been anything on the medical student curriculum and even GP registrars don't get any specific training.'
'Now that people are able to access that training, they are really keen to do so.'
In addition to the certificate, the RCGP is now developing a foundation course, which is due to start in April 2004.
The idea behind this is to prepare people who do not want to be a GPSI, but who want to provide national enhanced services under the new GMS contract, of which drug misuse is one.
'Many GPs have said that they would like to do the foundation course, because they need to make sure that they are topped up with knowledge,' says Dr Keen.
'It is a one-day course. They don't have to have that course to do national enhanced services, they just have to prove in their appraisal that they are up to scratch and this can be one way of giving evidence that they can do it.'
Dr Chris Ford is a GP who manages 140 complex drug misusers in her practice at the Lonsdale Medical Centre in London. She is also GP adviser to Substance Misuse Management in General Practice (SMMGP), a national network providing support and training to GPs. Dr Ford is a keen supporter of the foundation course.
'The RCGP is about improving standards, but for me the next step is promoting the foundation course,' she says.
'We are hoping that thousands of people will apply. This will offer some standardisation. There needs to be a standardisation of training so as to treat drug users in the same way.'
Dr Ford deals with multiple health needs at the centre. 'At the moment, 19 per cent of patients are HIV positive, 82 per cent have hepatitis C and 32 per cent have mental health issues,' she says.
But she feels that many people with drug problems can be managed successfully in general practice.
'I can offer my services as a GP, as well as HIV care and other, more specialised areas,' she comments. For the patient, it feels more normal to come and see me in general practice instead of using a drug service.'
Dr Ford describes the service provided at the medical centre as a whole-systems approach. She works with pharmacists, receptionists and local specialist services, as part of the shared care system, and says that she couldn't work without them.
'We also have some local GPs calling us up for advice every now and then,' she adds.
Dr Ford is disappointed that drug use management is to be a nationally enhanced service in the new contract.
'It should be seen as standard general practice,' she says. 'There is potential to earn money in this service, but who will pay it? We will just have to see how it pans out, but there is a slight uncertainty about what is going to happen.'
For the time being, however, Dr Ford is providing a way for drug users to gain access to the treatment they need.
'I love my work here - I feel we are good at managing chronic relapsing conditions and that is what drug misuse management is,' she says.
For further information on the RCGP certificate, please call
The course duration is one week, spread over six months.
To apply, you must contact the RCGP
This year's course starts in November and the cost of training is pounds 1,200. This can be obtained as funding from your local PCT, but these funds do not cover locum costs.
Case Study - Dr Miriam Brown
Dr Miriam Brown is a GP with a special interest in drug misuse at the primary care clinic for drug dependency in Sheffield. She completed the RCGP certificate in 2001. 'The most significant thing the certificate did for me was to help me look at the evidence,' she says. 'For example, the evidence that methadone maintenance treatment works. The second you put someone on methadone you bring about harm minimisation. All the research shows over and over again that for patients on methadone, morbidity improves, crime rates drop and health improves.' There are 400 people on the list at Dr Brown's clinic. They are referred from GPs who do not want to prescribe or are stuck with prescribing. Most of the time they are from probation services or referral schemes for drug-related crime, and others. 'We substitute heroin for either methadone or buprenorphine,' she explains. 'We put people on a maintenance dose and motivated clients reduce. One of the things I learnt on the course is that if you only reduce, your relapse rate is higher. Certain clients need to be maintained.'
Dr Brown recommends the course to GPs...
'The biggest thing it gave me was an opportunity to reflect, which in busy practices is difficult. It covers a whole spectrum of prescribing and complex ethical issues, so it can be pitched at anyone's level. GPs at any level will get something out of it, even if you are already prescribing'.