Post-its from Practice:
Complex people with complex problems need complex care (Oct 2010)
The urgent message to ring Carlos's social worker surprised me, as I had said my goodbyes to him about six weeks earlier when he moved into his dream flat in another borough. I rang back and discovered that Carlos wanted to return to the hostel (which he had been trying to leave for the past two years) so he could come back for treatment at the surgery.
We had treated Carlos for five years and during that time he really changed. The first time the outreach team found him, he was on a park bench, surrounded by empty cans and obviously distressed by voices he was hearing. They brought him in, got him a place in a wet hostel and generally cleaned him up. They then asked us to help with his mental health, drug and alcohol problems. He was drinking 6-10 cans of 5% lager a day, as well as using heroin, crack and benzodiazepines. He spent much of the first appointment repeating how he didn't want to go into hospital, as he wasn't mad and how "they" didn't treat him right. He had insight and had engaged well with the outreach team so I assured him he would not be admitted.
Over the next few weeks he settled well on 16mg buprenorphine and 20mg diazepam. He continued to hear voices and to drink but both reduced. The psychiatrist who visited the hostel diagnosed schizophrenia but was unable to get Carlos to take any medication for this. I tried a few anti-psychotics and was pleased when he began to feel much better on 2mg risperidone twice a day. Screening showed Carlos had chronic hepatitis C and early cirrhosis. He understood the link between his liver and the drinking, but he felt that alcohol consumption helped his mental health.
Over a relatively short period in treatment he began to look and feel much better. His mental health markedly improved. He settled into a routine of seeing us fortnightly and was working on his alcohol problem. He set goals: to get his own flat and to stop drinking.
He always said that his visits to the surgery were more important than his prescription. As he is Italian and loves a good coffee, he always treated himself to a large cappuccino from the Italian deli on his way to us and chatted to the receptionists while waiting. He often remarked that he felt normal as he was being treated as normal.
After successfully completing another community detoxification from alcohol, with support, he was able to remain alcohol free for three months and soon after; he was really excited to get the keys to his own flat. He had chosen to move to an outer London borough to distance himself from friends who drank and used, and to be closer to his brother. I had discussed with Carlos that this would mean he would need to receive treatment elsewhere, which he reluctantly accepted. I looked for a GP who would take on all his care but as he is a complex person with dual diagnosis this proved impossible. He therefore ended up being transferred to a "specialist drug service", which had recently been tendered to a third sector organisation.
That was where the problems began. Firstly he was put on supervised consumption, even though I explained he was completely stable on his daily pick-up, never used on top and all urines confirmed this. Subsequently they wanted to reduce him "going for the drug-free aim", although he felt the buprenorphine helped his voices. They also felt he didn't need his risperidone. These events led Carlos's social worker to report that he was near to relapse, but explained that the worst thing for him was that he wasn't being treated "normally".
I rang the service and confirmed the social worker's reporting of the events. I hope they will change their regime for Carlos but what worries me is their lack of understanding of Carlos as a person and the complexities involved. Payment for outcomes may be a good way forward but it must understand that all people who use drugs are different. It must be able to create a range of outcomes that consider severity and services need to be able to provide for complexity if they are going to take on care, particularly if they carry the mantle of "specialist". Being totally mentally and physically well, and abstinent, may not be achievable for all people and getting one domain right, such as housing, can only work if it is part of a well considered package of care that respects and balances the needs of the person.
Carlos believed, as did we, that a new flat out of the area was the next step on his journey. But - it can only be a step forward if he receives good care as well. At the surgery we do want the best for people, and it is great if that means being drug free, but not at the cost of their overall health and well-being. Carlos has made huge leaps forward, but I fear for him and other patients with complex needs; he needs access not only to a new home but also to good care.