Conference Reports & Presentations:
RCGP 1st National Conference (Apr 1996)
Managing Drug Users in General Practice
26 April 1996
Report produced by Jean-Claude Barjolin, Chris Ford & Conference Committee
Historically there has been much debate about the role of general practice in the management of drug users. Policy has ranged from encouraging GP involvement to active discouragement coinciding with the setting up of specialist centres in the late 1960s. A polarity of views has emerged on the appropriateness of general practice as a site for the care of drug users.
However, the last few years has seen an increasing number of GPs becoming involved in the management of drug-users and a variety of local schemes to facilitate their involvement. This has occurred for many reasons which include the spread of HIV together with more widespread drug use.
No GP can now avoid seeing drug using patients, whether knowingly or not and whether they offer help with their drug problem or not. Taking drug-users onto practice lists and offering help with their management creates specific and unique problems for those who elect to take up the challenge. These include: additional consultation time and remuneration concerns within the context of generally increasing workloads; fear of this client group and their problems; the lack of training, skills and support; that this is a specialist area lying outside of contractual core medical services; and the view that this is not a medical problem but a self inflicted/social problem.
The conference was intended to serve to provide GPs in particular, with a forum for debate and focus in light of several inter-linking and recent developments:
10th May 1995 'Tackling Drugs Together' (Ref 1) - A Government White Paper outlining a three year operational drug strategy for England which recognises increasing and changing patterns of drug use. This implements national and local co-ordinating structures through Drug Action Teams and Drug Reference Groups and attempts to harness varying agendas within a set of national objectives.
Responding to a purely client centred agenda of drug users needs may become more difficult in light of the document's emphasis on abstinence, crime reduction and primary prevention. Harm reduction, which is mentioned, might possibly increasingly need to be justified under the crime reduction umbrella as well as reduction of health risks.
Low general practitioner morale and a feeling of an inexorable increase in workload partly linked to a shift of secondary care into primary care, without adequate resourcing or reward.
'The 1995 LMC [Local Medical Committee] conference declared that the treatment of drug misusers was not "a core service of general medical practitioners" (Ref 2).
General Medical Services Committee (Annual Report 1996) (Ref 2) reported 'The growing pressure on GPs to undertake the specialist treatment of drug misusers is alarming the GMSC.' It reflected the LMC position stating that 'GPs' participation in the specialist care of drug users falls outside core general medical services and should be funded adequately and separately from the GP contract'.
The document EL (95) 114 "Reviewing Shared Care Arrangements for Drug Misusers" (Ref 3) published by the Department of Health on 12 October 1995 and sent to all Health Authorities. The document asked what arrangements for shared care were in place and what HAs were doing to address this issue. The policy nudge to actively develop GP involvement presented concerns to GPs, in particular, the statement that 'where GPs are prescribing for drug misusers, this should be considered part of core medical services'.
The Task Force to Review Services for Drug Misusers (Ref 4). Due in January 1996 but finally published 1st May, one week after the conference, a treatment effectiveness review by the Department of Health which is likely to have significant influence on types of services being funded/supported. Recommendations supported GP involvement and the development of shared care, but highlight the need for specialist training and for additional payments to be considered where GP services exceed the requirements of general medical services (see Task Force Review, GP section 4.7 pp 26-32 of report).
This was a one day conference hosted by the HIV/AIDS Working Party of the Royal College of General Practitioners to explore and debate current practice and concerns around 'managing drug users in general practice'. Normally such discussion occurs within specialist service forums. The conference served as the first national GP led debate around the role of primary care.
- To examine the role and function of GP in the management of drug-users.
- To critically explore the role of general practice within the provision of services available to drug users and relationships between services.
- To consider the specific and implicit difficulties of generically managing this patient group.
- To explore and identify models of good practice (encompassing shared care), that are necessary and appropriate to drug users.
- What is shared care and is it possible?
- Are different models of shared care transportable and is it dependant on the local area?
- How can GPs influence strategic development of services locally and nationally?
- Is it core or not core GMS? Is there consensus and what is an adequate reimbursement?
- What are the possible pitfalls and resourcing/policy implications of GPs agreeing to take on this work?
The conference generated considerable interest and was hugely oversubscribed. Numbers were kept to the agreed maximum for the venue with priority weighting given to GP places to reflect the aims of the conference. In the event 78 GPs attended together with 20 other health professionals.
Delegates called for the clarification on the role of GPs in the management of drug misusers and for more training and resources. A four point statement was agreed at the conference. Delegates unanimously agreed that:
The statement was also sent to and calls on the Department of Health, General Medical Services Committee (GMSC), the BMA and the Royal College of General Practitioners to take appropriate action to address these concerns.
It was argued that at the broadest levels that GPs already and always have been involved in treating substance misuse, but that the actions of the Brain Committee in 1965 encouraged the de-skilling of GPs in this area along with the development of Drug Dependency Units as specialist services. Within the more general culture of shifting workloads in the move toward a 'Primary Care Led NHS', GPs are presently citing the following reasons for not wishing to treat drug users:
- Lack of training and support.
- Lack of time - too many tasks accumulating in general practice.
- Ethical uncertainties over prescribing.
- Not a medical problem - self inflicted/social.
- Fear of overwhelming numbers of users.
- Wary of harm reduction & maintenance, and uncertain over aims of treatment.
- Drug users can be seen as demanding, devious and violent.
- Need for resources and payment to acknowledge the significant extra work it involves.
The failure of the 'Drug Dependency Model' to be able to treat the increasing and significant numbers of drug users was acknowledged together with the possible client benefits of a local GP/primary care service.
|4.2.1 Case study:
The user speaker at the conference commented that when she had wanted help in the early days at her local DDU she had been asked to i) wait too long ii) jump through too many hoops before being accepted into treatment. She voted with her feet and continued to use for a further 5 years before looking for help again. It took 10 years to find help in general practice and has been settled there for the last 8 years.
A primary care service can be accessible, more normalising and inconspicuous, with the benefits of a multi-disciplinary team to meet the overall health needs of the individual and their families. If it is accepted that drug use tends to be a chronic relapsing condition, general practice is certainly well versed in dealing with this model through other conditions such as diabetes and asthma.
GP involvement can be flexible in its response and levels of intervention, as different areas also have different needs - different needs will present from rural, suburban and urban areas and where different models of secondary services have been set up.
There was agreement with the LMCs and their national conference, the GMSC and now the Task Force Review (Ref 4), that whilst all GPs should be meeting the general medical service needs of the patient, they should maintain a choice over their level of involvement with substance misuse management. Developing shared care arrangements with drug agencies needs to accommodate a spectrum of GP involvement from GMS only to specialist GP clinics.
Dr Katherine Orton presented three key levels of GP involvement:
- Basic = general medical services only
- Shared = establishment of protocol with drug agencies
- Total = practice-employed drug worker
The RSDC report (Nov. 95) 'Shared Care, Shared Barrier' (Ref 5) identifies five possible levels of interventions:
- No provision of service to known illicit drug users.
- Provision only of General Medical Services.
- Provision of drug-related interventions under direct instruction.
- Provision of drug-related interventions with specialist support as required.
- The "specialist" general practitioner.
The following points arose in discussion:
Clarification over treatment options possible within general practice is also important. Do we accept that methadone maintenance, which is well researched and of proven worth, may be the most appropriate treatment for general practice?
Harm minimisation with aims around reduction in damage to health, stabilisation of lifestyle and hence a reduction in crime may need to be our primary focus. Work around striving for abstinence might possibly be better directed to the specialist services. It is important not to forget that problematic drug use (together with poor health) has many roots, and that poverty, deprivation, unemployment, alienation, and lack of hope all play their part. When the user speaking at the conference was asked what would have help would have been most useful with her drug problem, she firmly answered 'decent housing'.
- If abstinence is the only benchmark, then there will be lots of failures. Harm reduction is about short term gains and short term goals. Patients should not be reduced or pushed towards abstinence until they are ready.
It is consequently legitimate for GPs to see their role as helping to keep drug users alive while they, the user, decide what to do about their drug taking - keeping the patient alive whilst they work it out.
The following health needs & facts were acknowledged in one of the workshops:
GPs are well placed to provide overall health care and which could include:
offering testing and vaccination to all users for Hepatitis B; testing and counselling together with a sensitive and informed approach can be offered around HIV and Hepatitis C; dual diagnosis needs to be remembered and is perhaps one area that specialist help may be needed.
Conference thinking as reflected in the consensus statement, took the view that the management of drug users can be successfully undertaken by GPs, and that it is also an area of work that should be encouraged and supported.
Instrumental to the notion of support is that post-graduate training on substance misuse should be more broadly available for GPs. This should be for GPs who both do and do not wish to take on an 'extended' role in the management of drug users. It is vitally important that substance misuse training should also be present within the undergraduate syllabus.
Most participants at the conference stated that they had had little to no training around substance misuse, even those who had qualified in recent years. It was felt that this training should also be available to doctors who continue to work in hospitals. The GP training would benefit form being locally based and relevant to the changing drug use patterns.
It was felt that all GPs should be offering general health care as GMS to drug users, and be willing to assess and refer patients as appropriate. However, the decision to take on any extended role in the treatment of drug users should remain optional and should be supported by locally organised GP training and support schemes. Such schemes could also address administering remuneration.
Based in south London covering Lambeth, Southwark and Lewisham and represented by Dr Clare Gerada. Clare found that 5% of GPs were seeing 50% users and that orthodox training sessions alone appeared to have no impact on these figures. Training was found to be better conducted in a clinical context on a case by case basis. A Nurse Consultant position was established within the GP led scheme which was user friendly to GPs, offering a menu of options such as in practice training and joint consultations.
The key lessons to be learnt were that:
- there is no point trying to get resistant GPs involved
- change is a slow process
- trust in individuals rather than institutions
- must have a responsive secondary service
Based in Edinburgh represented by Dr Judy Bury. Edinburgh had a considerable public health threat of HIV amongst injecting users which served to mobilise GPs into action. As GPs had tended not to see drug users there was no legacy of bad experiences acting as an obstacle to involvement. The specialist service were also committed to taking the hassle out of prescribing. 79% practices were prescribing in 1995 from 41% in 1988, with 80% of GP referrals to specialist service.
The key 'plus points' learnt from this type of service are:
- users stay in contact with the GPs
- specialist services are less likely to get clogged up
- care of drug users is 'normalised' by being seen in the GP surgery
The key 'minus points' learnt from this type of service are:
- with more than 500 GPs involved, there is more inconsistency of approach
- more risk of double scripting
- more risk of leakage
- most important - if you see drug users, you get problems, so you need training and 'know how' in order to cope
There is now some disillusionment from GPs:
- Less HIV, less commitment
- Many realising how difficult it can be to 'get users off'
- CDPS is now too busy, a victim of its own success, sending users back to GPs sooner than before - less GP support and more hassles.
Based in Brent and Harrow represented by Dr Chris Ford. SMP was set up in 1995 in an area of traditionally low GP involvement; less than 5 % of GPs actively involved in prescribing. It offers a combination of on-going GP led training, support groups, GP led good practice development, a prescribing incentive payments scheme. It also facilitates links with specialist services, and is involved in local service development & strategy through local provider forums and commissioning and planning networks.
There was consensus that additional resources should support this work in primary care, and most delegates agreed that such arrangements should incorporate individual GP remuneration for substitute prescribing. Schemes were outlined that are attempting to harness the need for GP training, support, and remuneration together with involving GPs in the local and national debate on the 're-configuration' of local services.
The balance of resources and workload between primary and secondary care is a question that needs addressing both at a national level and within local commissioning contracting networks. This is especially so in light of the Executive Letter 'Reviewing Shared Care Arrangements for Drug Misusers' (Ref 3) and the recommendations of the 'Task Force to Review Services for Drug Misusers' ((Ref 4).
The Department of Health position on the nature GMS, the availability of funding for GP remuneration, together with the broader resourcing implications of policy in relation to both primary and secondary care, appeared somewhat uncertain or at least unclear at the conference. However, the DoH seemed to support 'in principle' the notion of extra funds if the GP is engaged in providing a specialist service as the main carer. The 'Task Force' recommendations have also since gone some way towards supporting this.
The more recent DoH response to the conference consensus statement welcomes the 'Task Force' recommendations and makes clear the following:
'The Department recognises that GPs and other members of the primary health care team may require appropriate support if they are able to offer shared care arrangements and that there can be barriers at present to developing that role... Where GPs provide a specialist drug misuse service, sometimes acting as a substitute for the specialist drugs agency and providing a more wide-ranging and complex service, then this is considered to lie outside the terms of General Medical Services... Your consensus statement is a helpful and positive contribution.'
- Peter Dunleavy - Drug Services Team, Department of Health, 15 May 1996
(Ref 4, see GP section 4.7, pp 26-32 of report)
The Task Force report, May 1996, a treatment effectiveness review commissioned by the Department of Health is likely to have significant influence on types of services being funded/supported.
The report mirrors the RCGP conference statement in many respects, highlighting GP responsibility for: the physical health needs of drug misusers; for identifying/assessing drug misuse; and for promoting harm minimisation and appropriate referral. It highlights the need for specialist training and for additional payments to be considered where GP services exceed the requirements of general medical services.
It also clearly pushes for health authorities to encourage the development and expansion of shared care with appropriate support for GPs and clarification of respective roles of the GP and specialist services.
The role of GPs in relation to secondary or specialist services was considerably debated. Workshops were run on different possible models for shared care and how to work in areas which both do and do not have specialist services. The point was made that specialist services do not necessarily just mean traditional statutory consultant psychiatrist led or hospital based service.
The continued need for such services was indirectly apparent in the conference statement around appropriate referral, and generally acknowledged throughout the conference in terms of the need for support for GPs who provide either GMS only or an 'extended role' . Specialist services certainly need to be open and flexible and should have real dialogue (regular communication, supportive and facilitative links) with other providers including primary care.
If GPs are being reimbursed for treating drug users and being encouraged to develop closer working links with specialist agencies towards a possible 'shared care' model, it seems important that appropriate patients are seen in respective services and that open two way communication and referral channels exist.
As to what shared care actually means (would not improved communication be a more realistic and practical goal?) and whether it can be achieved in this area of work remains to be seen.
Care needs to be taken to ensure that the shared care notion does not simply amount to an argument for reducing specialist services, and particularly so if there is no corresponding increase in resources for primary care. Primary care must not become a 'cheap and unsupported dumping ground' for provision of services. Increased primary care involvement will only be sustained with effective and well resourced specialist care services.
Specialist services may need to become much more innovative in how they work with general practice. This may include a more community focused and outreach role; more GP support and surgery clinics; taking on more the role of central assessment and stabilisation; referral of more stable clients to GPs; together with a focus on primarily specialising in management of the more chaotic clients.
If shared care is to be encouraged and take shape, local protocols will need to be jointly developed in order to clarify roles and responsibilities of both primary care and specialist services. This would probably ideally happen within a framework of suitable and agreed service philosophy, local prescribing and treatment philosophies, and good practice guidelines. A change in actual practice to match these aspirations would probably be incremental and rely on developing and maintaining good communication, understanding and trust over time.
Examples of where this is not happening came up throughout the day. An example being of 'old style consultant' led services which have not really changed since the services began in the 1960s, who have not taken on harm reduction and who are unsure about the role of GPs. The latter may be to do with simply misunderstanding primary care or concerns about changing roles.
A workshop identified some possible considerations and pitfalls of GP reimbursement which include the following: the need to fund staff adequately and negotiate a realistic fee; the need to standardise fees; the need to calculate the cost of providing services to drug users in general practice; to examine where funding is coming from (not just secondary care but Home Office/Police budgets?); payments should not allow a shift of services to primary care without other resource input/support; payment alone is not enough - need to include training, audit, good practice development, and GP support forums.
'Tackling Drugs Together' (Ref 1) reflects to a large extent a traditional (and some might argue ineffective) emphasis on primary prevention and enforcement. Responding to a client centred agenda of drug users needs may become more difficult in light of an emphasis on abstinence, crime reduction and primary prevention. The white paper seems to highlight a role for 'health' which may increasingly move towards incorporating greater social policy goals. For example, harm reduction which is given mention, may increasingly need to be justified under the crime reduction umbrella as well as reduction of health risks.
The Executive Letter 'Reviewing Shared Care Arrangements for Drug Misusers' (Ref 3) seems to be promoting shared care for drug users when the structures and understanding are not yet in place to be able to support this. GPs may feel pushed into it and most specialist providers appear to have not yet to begun to think of the implications of this on their services.
In terms of a concise summary, Harry Shapiro from the Institute for the Study of Drug Dependence (ISDD), who acted as conference raporteur suggested that the consensus statement stood as a summary of 'group feeling'. However he added the following useful analysis:
Decisions taken in the 1960s about the degree to which GPs could treat drug users have worked to the detriment of both. What we have now is a situation whereby:
- drug users are unable to take full advantage of the localised and widespread medical care offered by GPs:
- successive generations of GPs were given little or no training so that the idea of the difficult and demanding addict became a self-fulfilling prophecy;
- addiction treatment is now concentrated in a few specialist services who cannot cope with the workload.
Despite all the difficulties, there are GPs out there who are willing to work with drug users (as evidenced by interest in the conference) and there are drug services who want to work with GPs in a properly organised system of shared care through GP liaison schemes etc.
However, we are now faced with having to correct the policy mistakes of three decades in a climate of rapidly escalating drug use, extra demands for services and diminishing resources. Progress can be made, but there has to be a recognition by all those involved (Government, professional bodies, Health Authorities and so on) that GPs have to be brought back 'into the fold' of training, support and remuneration - as highlighted in the last paragraph of the Consensus Statement.
It was clear from the energy and excitement at the conference that a lot of GPs are already actively involved in caring for and managing drug users. The conference was validating of this role. There are many examples of effective practice embracing a diversity of models and responses influenced by local need, demography, drug use prevalence and incidence, and the characteristics of drug use.
It is evident however, that there is still much to be addressed, particularly the 'core' and 'non core' role of GPs in managing drug users, and the GPs' role in contributing to the development of local service provision. This clearly cannot be separated from local and national debate on either the role and function of general practice or from the national debate on drug policy and how this impacts upon general practice( broadly or more specifically in its' task in managing drug users).
As the national debate continues, it is evident, and indeed there was significant support for the motion, that this forum for debate and discussion should be maintained on an annual level and supported by the active dissemination of information to GPs. The SMMGP (Substance Misuse Management in General Practice) newsletter was also launched at the conference which will be written by general practice for general practice. Most addiction journals and magazines print very little that is related to primary care. A number of conference participants agreed to write about a variety of topics which will add to the debate and pool of knowledge from a primary care perspective.
GPs and primary care can be seen at the forefront of the health service response to drug misuse. Now it is both timely and appropriate to debate how GPs can be heard in the development of service provision, and how they will inform the national debate on the management of drug users.
"The conference showed that we have all become specialists with a lot of experience in working with drug users in primary care. The Government talks about moving to a primary care led National Health Service. We should recognise that in this area primary care is leading the way. People should take notice of what GPs say."
1. Tackling Drugs Together: A Strategy for England 1995-1998. May 1995. HMSO. London.
2. General Medical Services Committee. Annual Report (1996) Drug misuse section, 20.
3. NHS Executive. Department of Health Circular. EL (95) 114 Reviewing Shared Care Arrangements for Drug Misusers.
4. Department of Health (1996) The Task Force to Review Services for Drug Misusers. Report of an Independent Review of Drug Treatment Services in England.
5. Resource & Service Development Centre (1995) Shared Care, Shared Barriers. Reviewing Shared Care Arrangements for Drug Misusers. Notes supplementary to District Health Authority Responses.