Post-its from Practice:
Some do, some don't, some will, some won't (Aug 2013)
I became interested in working with people who develop problems due to their drug and alcohol use very early in my GP career. Since then the patients I have met have reinforced the importance of providing such a service in primary care. However a significant number of GPs do not work with people who use drugs and alcohol and some practices even send out a clear message that this group isn't welcome.
On the one hand there are practices like ours, in which all of us from the receptionists and on, regard this work as a priority and where a few years ago our list was closed, unless the person had a drug problem! This compares with other practices where from the outset it is clear that "your sort" isn't wanted. Why the difference?
Medical education plays a significant part in attitudes - as undergraduates we receive very little teaching on drug and alcohol problems. Although this has improved a little over the past few years, there is still a great deal more that could be delivered, as evidence suggests that young doctors are quite happy to engage in this role.
At a postgraduate level it is fairly hit and miss. I was fortunate to have a GP postgraduate tutor - Dr Ian Fletcher - who passionately believed in primary care "substance misuse services" as we called it then. He arranged a session for the West Midland GP registrars and one of his patients agreed to come along and share his experiences with us. This was a real eye opener to me, allowing me to see drug use not as a self-inflicted problem but as an attempt by some individuals to try and deal with the trauma they face or experience as they go through life.
Dr Clare Gerada, the current chair of the RCGP council has been a leading light in encouraging primary care to provide good quality care around substance use. She is also keen to increase the length of GP postgraduate training from 3 to 4 or even to 5 years. This would provide an ideal opportunity for the RCGP drug dependence and alcohol training - currently optional for both GP registrars and established GPs - to be a part of the core curriculum.
Another problem relates to GP contracts. The vast majority of GP practices have either GMS (General Medical Services) contracts which apply across the country and do not include or specify providing treatment for drug or alcohol problems; or PMS (Personal Medical Services) contracts which are locally agreed for a range of other services above and beyond GMS, but again many would not have a specific substance misuse category. This doesn't mean GPs can ignore the physical or mental health problems of people with drug and alcohol problems but they are not obliged to offer OST, community alcohol detoxifications etc. unless they have signed up to specific local contracts.
There also remains a cohort of (often older) GPs in practice who trained at a time when GPs were actively discouraged from getting involved in this field. I hope that as time goes by they are being replaced by more receptive GPs and that it will become as normal to work with those with drug and alcohol problems, as it is to treat someone with diabetes or hypertension.
For this to occur the training needs to be right, the support structures from commissioners, drug workers, and the more experienced GPs need to be in place and the current investment in services needs to be maintained. Given this, my aspiration is that in time, the maverick GPs will be those that are not involved in working with drug and alcohol patients. Until then, I will continue to educate and inform all GPs about providing primary care treatment to this interesting group of patients, giving them the chance to recover from problematic drug and alcohol use in their own communities.
For more information about the RCGP Substance Misuse and Allied Health certificate courses in the management of drug and alcohol misuse, see the RCGP area on the SMMGP web site.