SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Conference Reports & Presentations:
RCGP 5th National Conference (May 2000)

Royal College of General Practitioners (RCGP)

Managing Drug Users in General Practice
Are we Drowning or Riding the Waves?
The Treatment of Drug Users in Primary Care

10-11 May 2000
Leeds
Supported by the RCGP and the RCGP HIV/AIDS Working Party

Conference Report by J-C Barjolin & Dr Chris Ford

Conference Supported By

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Conference Supported By

Conference Organising Committee
- LEEDS ORGANISING GROUP
Carol Turner
Nat Wright
Susannah Lawrence
Louise Tiffen
Alison Field
- ON-GOING GROUP
Chris Ford
Jean-Claude Barjolin
Berry Beaumont
Claire Gerada
Brian Whitehead
Judy Bury
Jenny Keen

Conference Organisers - RCGP Courses London
Jennifer Goulding
Lisa Liu

Report Editors
Dr Chris Ford
Jean-Claude Barjolin

Rapporteur
Lyn Summers

Educational Grants
Brent & Harrow Health Authority
Camden & Islington Health Authority
East London & the City Health Authority
Ealing, Hammersmith & Hounslow Health Authority
Kensington, Chelsea & Westminster Health Authority
Standing Conference on Drug Abuse (SCODA)

Commercial Sponsors
ScHering Plough

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1. Foreword

Welcome to a delayed version of the conference report. We had some technical and computer problems that damaged much of the verbal and electronically recorded information. We felt there was enough good material to print the report.

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2. Introduction & Background to the Conference

Leeds was this year's host to the 5th National RCGP Conference 'Managing Drug Users in General Practice 'Are we Drowning or Riding the Waves? - The Treatment of Drug Users in Primary Care' The conference was again full to capacity.

Conference Background

The Conference was first held in 1996 as a GP initiative. It was felt that the few GP's or shared care schemes working with drug users were experiencing common concerns, yet working largely in isolation. Many seemed to have little or no support from specialist drug agencies.

The first conference looked at the 'why and how' of managing drug users in general practice. In fact it addressed the question as to whether general practice should be managing drug users at all? 1997 focused on 'embracing the diversity' of managing drug users in general practice; diversity in terms of the variety of roles and approaches within general practice and in terms of multi agency working and shared care. 1998 had a focus on a national structure of support, in order for primary care to influence this field of work within the new proposed and evolving primary care led NHS. 1999 needed to look at the changes in primary care and how they would affect substance misuse, the new Clinical Guidelines and the broadening and increasing drug problem and 2000 looked at the many changes that were happening in this field.

Aims of the Conference

To bring together GP's and other health professionals working with drug users in general practice to examine, explore and debate current practice and concerns.

Developing the Conference 'initiative':

The new Department of Health Clinical Guidelines had three members of the Conference committee participating on the working group.

Organisation and Support

Has been given by members of the Leeds and On-going Conference Committee, the Conference and Courses Unit of the RCGP

Future Activities

For further information or for comments on the report please contact Dr Chris Ford at the
RCGP, 14 Princes Gate, London SW7 1PU
or Jean-Claude Barjolin, GP Network
c/o SMAS, 46-48 Grosvenor Gardens, London SW1W 0EB

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3. Consensus Statement 2000

As in previous years, delegates agreed a clear consensus statement arising from discussion on the day:

  • Conference Statement 1:
    "This conference welcomes the increased involvement of primary care in services for drug users and the development of the Primary Care Network. In order to continue to develop this work primary care requires a commitment to training at all levels, increased resources for shared care and access to specialist support. The emphasis should be on equitable and rapid access to methadone maintenance and other evidence-based services.

    Maintaining current levels of commitment in the primary care community requires urgent dialogue between the Department of Health and the profession, recognising the strong evidence-base underpinning drug treatment and methadone maintenance treatment in particular. Health professionals involved in this work should be held professionally accountable but should not be inappropriately targeted by the criminal justice system."

  • Conference Statement 2:
    We regret that there was only minimal consultation on the Home Office proposal for changes to the licensing regulations for doctors working in the field of drug misuse, and recommend that the consultation period should be extended and the proposal more widely circulated.

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4. Presentations - Day One

4.1 Welcoming Address & Introduction - Dr Nat Wright

Welcome everyone. For those of you who have not been before - this is an incredible means of support.

When I started working here I didn't know anything about drugs and I was working in deprived area of Leeds - unfortunately that is true of a lot of people here - this client group can be both demanding and challenging but it also offers an exciting road ahead.

The culture of this conference is not having all the answers but bringing together a multitude of people to share skills so that we can work with this client group effectively.

Some of you are learning to swim some of you are a bit further forward and some working for a longer period and who are feeling a bit ragged and worn out

No strategy for our own practices means we end up with no control - this is a good time to take time out and look at the service we offer and hopefully receive support from those already working effectively.

4.2 Ensuring Quality Care: Clinical Governance & Addiction Services - Gillian Tober

The lack of specialist support in some parts of the country is proving problematic but it is being developed. The increased workload is a genuine fear. The training we offer in Leeds is designed to solve GP problems not create new ones.

A review of a skills deficit in medical schools carried out ten years ago has proven a need for training. Some GP's have had bad experiences with patients with substance misuse problems. At one end of the spectrum are patients asking what they should do and at the other end where the client knows what the problem is and can offer the GP the benefit of their experience. A lot of patients also fall into the void in between these two extremes.

We need to be aware of clinical governance, guidelines and protocols, which give support to workers and manuals that show how to deliver the service. Video recorded practice allows good practice to be shown to peers and makes us aware of our own practice.

We need to look at outcome evaluation so we know what we do and if it works.

There is an idea that addiction patients do not get better. A study carried out on over 200 drug users over a 3-month period showed that 50% had reduced their drug use. This shows how important it is get patients into treatment.

Change needs to be measured. Health and psychiatric outcomes possibly need to be politically meaningful as well. This appears to be aimed at the criminal justice end of treatment.

Questions

1) Very important issue - threat to standards are the large number of GPs who will not treat drug users in any way. GPs who do not engage with drug users are contributing to this standard being missed.

Gillian Tober Answer:
Getting GP's on board is a slow process but GPs are not unique in this - survey shows that if training is provided early enough i.e. to undergraduates and beyond then GPs will feel easier about working with substance misuse problems. The normal reaction is to say it's not my job if we don't know how to deal with something

Training has to be provided within medical education - think things are changing and this is one of the routes. Without training GP's feel isolated and cannot deal with presenting problems around substance misuse. Support networks are desperately needed in order to facilitate this change

2) Will good protocols and guidelines save GP's from the judicial system should a situation arise which results in a tragedy?

Dr Susanna Lawrence Answer:
Because of recent situations around the country - GPs are quite right to show concern - however, if protocols such as the National Orange Guidelines are followed this will go some way to protect GP's who may face such a problem.

The judicial system has not quite caught up with what is happening with the Guidelines but it is felt that once they do, and hopefully this will only prove to be a short period of risk, GP's will feel unsupported in the decisions they make. Dr Nat Wright added that organisations that work in line with others then it would be safer

3) We are drowning in the work we have already without taking on more work that we can be criticised for. The key is having some sort of carrot - co-operation is fine but money should be provided for doing extra work along with the money comes the standards.

GP in North Kensington Answer:
Not necessary to have financial carrot - where he works there is monetary reimbursement but it still doesn't work the carrot should be support from specialist providers

4) In your study 20% GPs involved in shared care - sympathetic etc. Would you rather work with those 20% or the 80% who are not interested?

Gillian Tober Answer:
Obviously I would rather work with the 20% but you have to look at the whole issue - some of the 80% have not been trained or supported but do want to be involved, so I feel optimistic for a percentage of the remaining 80%.

4.3 Round Table Discussions - Facilitated Groups

4.4 The Developing Primary Care Network for Working with Drug Users - Jean Claude-Barjolin

I am going to talk for about 10 minutes on the Primary Care Network - SMMGP (Substance Misuse Management in General Practice) and then open this up to questions and discussions.

SMMGP is a growing primary care network attempting to support primary care in developing this area of work - on an operational, clinical, and planning level, but also to some extent on a policy level, helping to drive forward a primary care agenda and perspective.

1) Established by GPs who manage drug users

The first thing to say is that the network evolved from this conference - or the first Management of Drug Users in General Practice Conference in 1996. It is important that its origins and focus come from primary care and are a grass roots development. The conference and now the network is expanding from a small 'club' of a few hundred keen delegates and practitioners, into something that is fast becoming much bigger and possibly much more influential.

This is during a time when a new comprehensive drug strategy is being implemented, a time when primary care is undergoing fundamental changes, and a time when primary care has been given a central role in terms of shared care in the delivery of drug services.

It is also important in that shared care may not be the only or most important contribution primary care can make in the management of drug users in general practice. Primary care is increasingly finding its own responses to supporting this area of work, through things like GP Facilitation, Deputising and back referring to GPs, GP specialised generalist clinics and voluntary sector partnerships. These don't altogether accord with the specialist led model of shared care promoted in the guidelines. Primary care needs to be supported and encouraged in developing a range of models and approaches, as primary care probably best understands its own needs and ways of working. Specialists telling primary care how to do it may not always fit as the best model. The learning and changes need to be two-way.

2) Historical background

The 'British System' has been flexible with little overriding control or strategy until recently. The Specialist Services were set up originally with a view to general practice not having to do the work. But a pragmatic and flexible public health and harm reduction approach prevailed, with significant numbers of GPs choosing to remain involved in this area of work.

Recent policy changes and strategy development have moved the goal posts significantly. Strong encouragement is given to primary care involvement, and high expectations ride on the role of treatment generally in meeting broader and now quite politicised agendas. Treatment seems to be given a higher priority, but often justified as a vehicle for a criminal justice/community safety agenda. Primary care is in a time, yet again, of radical change, but potentially in a power ascendancy with the advent of PCG/Ts. So we are in to a completely new game.

3) Policy agenda change

Policy development has come thick and fast since 1995. All these developments generally push forward the role of treatment, greater and more formalised primary care involvement, enforced partnership working, centralised development and with it greater scrutiny of what practitioners are up to, and the more structured introduction of criminal justice, community safety and control agendas into treatment planning, affecting patients and practitioners.

4) Policy

So demand for treatment services has exceeded our ability to meet it. Primary care has a formal role to help support meeting this demand, as part of a broader comprehensive strategy. But this shift has been relatively sudden, and until recently there was little acknowledgement of the role of primary care, and little support available for it.

5) National strategy

The National Strategy highlights 4 main areas - Young people, Communities, Treatment and Availability.

But to me, treatment is seen as a central vehicle to achieving many agendas. It works, it helps meet political agendas - so the theme is lets push it out. We just have to be careful that we do not lose the balance with individual health and public health. GPs and primary care are about health and not social control - It looks likely that statutory services are increasingly likely to have their health and treatment agendas re-oriented by political agendas through funding criteria and centralised monitoring. Shared care schemes, headed up by statutory services with primary care, as junior implementation partners are likely to run into conflict of interest.

This is one good reason why primary care should organise and develop and share its own approach and experience.

6) The Guidelines on Primary Care

The national clinical guidelines on drug dependency management highlight the importance of primary care involvement. They express many good arguments - from a patient perspective, a rational service delivery perspective, and as part of the overall broader NHS changes - and the primary care led NHS.

7) Changes in Primary Care

The potential for primary care to become more influential should not be underestimated in relation to drug service provision.

Commissioning guidance does not rule out the possibility for PCTs to commission community drug services. Increasingly primary care, through PCGs is taking the lead and finding their own ways of supporting primary care and shared care, where local services are not flexible enough to respond.

I think we will increasingly see primary care led responses, which are not technically shared care, sometimes with voluntary sector involvement. If they work, they should be encouraged.

8) SMMGP network

So it seems that there is likely to be an increasing need for a Primary Care Network, and primary care focus to the development of drug services and the management of drug users in general practice. This should work with central guidance where possible, but also challenge it where it does not work. We should develop and share our own experience - what primary care has to offer.

SMMGP is in a position to take on this role. SMMGP evolved from this conference and a grass roots newsletter typed up on a few sides of A4, and circulated to a keen club of enthusiasts. We are now attempting to broaden out this experience and support.

We have an embryonic web site. We are linked to this conference as a practical and political hub and reality test for what we are doing.

The project is developing the roles of Network Co-ordinator and Primary Care Development Advisor - able to act on a local GP/PCG level but also on a HA, DAT, PCG planning level, as well as possibly at a national issues or political level.

We are doing some of all of this; the problem is it is one paid person, one post at present. Just me! But we are looking to expand the project/develop partnerships.

The network is well backed up by connections with this conference, a steering group and production group consisting of Clare Gerada (GP/Specialist/DOH/Conference organiser), Chris Ford (GP/Specialist/Conference organiser), Berry Beaumont (GP/Specialist/Conference organiser), Jenny Keen (GP/Specialist/Conference organiser), Don Lavoie of SMAS, where we are based, and Jim Barnard Enhancing Shared Care Project of Greater Manchester.

9) Newsletter 1

Until August last year the network had no funding, and was run passionately, but as an adjunct to other work by some of the production group. We produced and mailed several hundred A4 newsletters, and various areas copied more and disseminated them. This had become a successful formula, but we felt the need to expand, reach a greater audience and have more impact.

With sponsorship from Schering-Plough we now print 3000 higher quality newsletters. Individuals and organisations such as PCGs, DATs, drugs services, have contacted us to tell us that they photocopy and disseminate another 4000. We can guestimate that a similar number again do the same and do not tell us - giving us a probable circulation of 10,000 copies, achieved since December 1999.

For the two new format issues, December and March, we circulated promotional/information copies to PCGs, HAs, GP Tutors, Departments of Primary Care, DATs, Drug and Alcohol services with a view to giving primary care a visible and credible voice in those forums, showing that primary care is interested in this work, expanding our main mailing list, and gaining further copying and distribution through new networks.

We seem to be being successful in all of the above, with over 380 letters, reply forms back, usually very positive, pledges to copy and circulate 4000 more newsletters, and a doubling of our main mailing base to over 700 in less than 5 months.

10) Newsletter 2

We have people recognising the newsletter, requesting copies, seeing it as a credible and useful tool on a practical, clinical, planning and policy information level. We can continue to work with this, maintain something that works with central guidance, but is able to question it, is separate to it. It is a development of a primary care agenda to inform practice and hopefully thinking, service planning and development and policy.

We believe that far from just primary care learning from other providers, the existing experience of managing drug users in primary care can be contributed to the rest of primary care, other providers including specialist services, and the general experience of developing drug services.

11) Web site

This is still embryonic but is going to develop over the next year.

12) Future

The primary care network will help in driving a primary care agenda forward.

4.5 Closing Comments & Introduction to Day 2 - Dr Nat Wright

[Transcript unavailable].

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5. Presentations - Day Two

5.1 Welcoming Address and Introduction - Dr Chris Ford

Dr Ford welcomed delegates to the second day of the 5th National Conference Managing Drug user in General Practice stating that we had no idea when we started this conference four years ago that it would grow in this way. She was pleased that even in the current climate that so many of us wanted to continue doing this work, accept the challenge and develop into such a strong network.

A personal thank you to Jennifer Goulding, Lisa Luiu and the crew from the Royal College of General Practitioners who worked tirelessly behind the scenes to organise and arrange this conference - the unsung heros. It was important to thank all the sponsors who had helped to make the conference possible and a particular thank you to the Leeds Conference Group who had formulated an excellent programme.

She then went on to discuss the threats and opportunities at this time - are we drowning or riding the waves?

The last year had been a time of change for those of us working with drug users in Primary Care. We have struggled on occasions, ridden many waves but on the whole the experience has been exhilarating and we have not yet drowned, although at times we were glad that we were wearing wetsuits!

The arrival of new "Drug Misuse and Dependency" guidelines on clinical management have helped support shared care and stated very clearly that drug users have a right to care like any other patient. They have given GPs a framework to do this work but frameworks can be restrictive.

The guidelines have also brought with them the threat of discipline if doctors step outside the guidelines. A recent letter from the Medical Defence Union, which states very clearly "we are currently advising our members to adhere to the Department of Health 1999 Orange Clinical Guidelines. In addition they would be advised to satisfy themselves that they had relevant experience in order to treat drug addicts... Ultimately general practitioners must satisfy themselves that their practice is inline within the guidelines contained in the Department of Health booklet".

The guidelines also bring some confusing messages about the need for training. On the one hand it says that we must encourage more GPs to work with drug users but on the other hand it says unless you have done a certain amount of training then you should not do it. They also hint at further restrictions of prescribing options.

The Home Office has very recently sent out the first draft of their proposed licensing document. Dr Chris Ford felt that if the document was adopted in its presence form it would confirm the end of the "British system" where prescribing was dependent on the needs of the drug users not the license of the doctor. It would also severely restrict the treatment of drug users in Primary Care. She felt the licensing system must be challenged, as it was not about quality of care but about restriction. There was also concern that so few people particularly GPs had seen the proposed document.

Previously, UK drug policy had a Public Health agenda - we had a "healthy drug policy" which worked towards helping drug users to lead healthier lives and limit the damage to themselves and others. It was very easy for Primary Care to understand its role within this Public Health/Harm Reduction agenda. Since 1997 the drug policy seems to have moved away from health improvement and harm reduction and towards crime reduction. Crime reduction had become the primary aim of drug treatment. In itself it is a worthwhile outcome but not at the cost of health improvement. It is less clear to see how Primary Care fits into this new agenda. She told a story of a colleague who had been asked to screen a drug user who was on a court order. If his urine had been positive for heroin then he was to be sent back to prison. This colleague asked for advice from the Department of Health who confirmed that she needed to do this. This is a marked role change for these of us working in Primary Care.

Recent drug policy, proposed drug licensing and the 'Orange Book' are all tending to be more restrictive and working against the last 10 years of Harm Reduction in the UK. Links with the criminal justice agenda are set to increase and it could move Primary Care into more of a "policing role" rather than health care provider.

Fear has also entered the arena of care of drug user in general practice. The arrest of two prescribing GPs in Cumbria and Exeter has added to this fear. We cannot comment on these cases and the history of these arrests is still far from clear but what is the scope and limitation of police interest in the treatment of drug users in Primary Care? Should the police have been involved in either of these cases?

Sadly some people involved in GP politics have used these developing policies and the above events have reason to suggest that prescribing to drug users should be decamped back into specialist services. This has tended to be doctor's who were never happy with the idea of normalising "drug users care in Primary Care". They have been supported by particular reactionary elements of the medical press. She gave examples of a few recent headlines out of one of the GP rags: "GP arrests threaten methadone policy", "I am too frightened to prescribe now", "Methadone related deaths rise"; "Shared care led to assaults"; "GPs urge to shun methadone prescribing in wake of deaths"; "GP driven from UK by Addict patients"; "more GPs refused to prescribe methadone".

These moves are against what we have been trying to achieve. These annual conferences, the SMMGP Newsletter, the budding Primary Care Network, the expansion of Primary Care facilitation and the increase of good, safe and support of shared care schemes are some of what we are going to hear about this conference. They also show that many of us are willing.

There are many other developments as well; the flourish growth of local drug users groups, the National Drug Users Network and the development of special interest group such as the Methadone Alliance; Action on Hepatitis C; and the Pharmacists working in Substance Misuse Group.

Many workers, doctors and others working in Primary Care and drug users being treated in Primary Care are committed to taking this work forward and need ongoing support and resources. We may need to learn better ways of how to surf the forthcoming waves together.

5.2 Normalisation & Social Exclusion

5.2.1 Different Models of Care: The Leeds Experience - Dr Susanna Lawrence

Like to do provide an overall context - treating addiction a ten-year strategy for Leeds. It was decided that there was a need to pull together, to treat the needs of people in the city.

What happened was a brainstorm to try and come out with a strategy. It has been passed and is now being implemented.

The City of Leeds has a population of 3/4 million, with lots of growth, but very divided. There are huge problems with depravation even though the city is economically viable. There is an ethnic mix of 11 to 13 ethnic groups.

There are 128 general practices divided into 5 PCG's in 16 localities, in order to cover the diverse communities and their local needs. We took stock and found huge variety across the city with ad hoc development, no money in some areas lots in others. There was no citywide consistency. This has improved but we still don't have consistency within the NHS. Most services are being provided by the voluntary sector. There are huge areas of unmet need and patchy quality of care. Unsafe prescribing and street diversion has improved since introducing shared care.

We have the Leeds Addiction Unit, St Martin's Practice; Leeds shared Care Scheme, Primary care team for the homeless and many others. There is minimal input from GPs that is provided at locality clinics.

Compulsory training for GPs who are moving into shared care with the provision of locums and we will reinstate training for practice managers. We would be expecting 20 clients per GP. The aim is to get 60 general practices involved and this will hopefully cover the issues of unmet need across the city. We need to recognise areas of hot spots in the City.

We think we have ironed out the key agency approach. Clients use a lot of different services that causes problems with their whole care. The client will be asked who they want to be their key provider. Hoping for improved communication between voluntary and statutory sector agencies.

5.2.2 Different Models of Care: The Manchester Experience - Jim Barnard

The Manchester experience is a rather inaccurate title as Manchester is just one of eleven drug team areas that our service covers. The 'Enhancing Shared Care Project' has been working for the past two years with the 6 health authorities, 10 DATs, 11 drug teams, 23 PCGs and approximately 1300 GPs across Greater Manchester. Each area has different needs, different strategies and different service models, as a result there is no one Manchester experience. However in this paper I am going to try and briefly explain our project, illustrate how it works and detail the present state of play as regards to shared care across the county.

The bottom line to our project is to increase access to general medical services for drug users but in practice this means helping to develop and enhance shared care across the area. This is mainly achieved through strategic liaison, advice and consultancy combined with the development and delivery of locally tailored training packages for those involved in service delivery. We also produce a quarterly newsletter for all GPs, pharmacists and drug teams in The County.

Experience and knowledge of many schemes nationally tells us that recommending one approach for developing shared care, without taking account of local circumstances and history is counter-productive. We have therefore helped to develop approaches and made recommendations, which are appropriate to local need and are flexible to changing circumstances. We have also sought to forge partnerships between the key stakeholders, which is essential in order to create the political, will necessary to move shared care forward.

We feel that we are in a privileged position when it comes to the development of shared care in locality areas. As outside facilitators we are seen as being outside the maelstrom of local politics and interests and thus a politically neutral. There is a vast array of potential stakeholders. Obviously there are the usual suspects such as drug teams, health authorities, GPs, NHS trusts and social services and more recently PCGs and PCTs. But we also include the criminal justice agencies, which are increasingly driving the treatment agenda and need shared care to create the treatment capacity to facilitate schemes such as Arrest Referral Schemes and Drug Treatment and Testing Orders (DTTOs). Also pharmacists are increasingly important as we move towards supervised consumption. Also drug users who need to support shared care for it to succeed. We have even included local politicians who get involved on occasions.

We started working preceding the setting up of a specialist primary care service that was to be independent of the two drug teams in the health authority areas. Social services and the other led one by the NHS trust. We saw our role as laying the groundwork for the new service and working alongside it in its initial stages. We therefore worked with the PCGs to gain their support for the service, with Drug teams setting up lines of communication and referral and GPs and primary care teams, so that they were aware of the new service and what it could offer them as well as gauging what they wanted from it. Alongside this we delivered training to those practices that expressed an interest in utilising the new service so that they were better prepared to engage with it.

This process continued once the service was set up of clinics and provided supervision for the manager. On exiting the area the service was successfully established with a high profile and had developed far more quickly and smoothly than normally would have been expected. We had identified pharmacists as interested stakeholders not least because of the pilot supervised consumption scheme in the area and we liased with the appropriate representatives so that their voice was heard and they were informed of developments.

In the second health authority area shared care had already been instigated in some practices as part of a national R&D scheme. It became obvious through visiting practices and offering training that levels of interest for shared care among GPs in this area were much higher than would normally be expected and that extending the shared care provision to cover all practices would be a fruitful exercise.

The Drug team were keen to reconfigure their services in order to achieve this and the health authority was broadly supportive but not very pro-active. However the NHS trust and in particular social services, which had joint line-management responsibility for the team, were very vary of moving forward on the issue. So we concentrated on activating the health authority to be more pro-active making them more aware of the benefits (not least addressing the drug teams 18 month waiting list) and relaying to them the positive attitudes of GPs locally. We also encouraged the drug team to remain enthusiastic and via a comprehensive primary care training schedule demonstrated the enthusiasm and preparedness of primary care services to take on the issue. By the time we left the area the trust and social services had agreed new structures for the CDT that would allow them to work across the board in a primary care setting.

We look at the stages of development of shared care as being split into five stages. Stage one is before shared care initiatives have been started, less than 10% of GPs are usually involved. A handful of GPs take an interest in the subject and usually prescribe for large numbers. Clinics can be difficult to control and there are fears of being swamped. There are no areas in greater Manchester still at this stage, though at the start of the project there were two, possibly three.

Stage two is 10-30% involvement, which is usually not difficult to recruit to with a sensible scheme. More enthusiastic GPs tend to get involved and see the logic of the system. However, at this stage there are usually several vociferous GPs who strongly oppose the development. One possibly two schemes are presently at this stage in Greater Manchester.

Stage three is 30-60% involvement. This is the most difficult phase. Progress may be slow. Much evangelism is needed. Those already involved may get cold feet if they remain a minority. Recruiting one or two previously vociferous opponents is important at this stage. Four, possibly five teams are presently at this stage.

Stage four is 60-90% involvement. This is usually quite easy. Practices see other practices coping well and appreciate that this is a useful addition to their service. Fears of being swamped disappear. Most GPs will be seeing their own long-term patients and will be more sympathetic about treatment. There will be less fear about misprescribing. Two possibly three teams are presently at this stage.

Stage five is 90-100%. This is hard work because one is dealing with most dedicated opponents of drug treatment. It is probably not worth putting much energy into this as you are dealing with the law of diminishing returns. Better to concentrate on supporting the existing services. Two services in Greater Manchester are currently operating at levels of over 90%.

By working with local stakeholders, making partnership and finding local solutions we have managed to positively influence progress through these stages in Greater Manchester. Basically Greater Manchester has comparatively high levels of GP involvement; in fact a recent survey found that it had the highest level outside London. Local solutions are the key.

5.2.3 Setting up a Service - Dr Nat Wright

I inherited a practice 4 years ago. There was lots of prescribing but no strategy. The key was getting a strategy going. For us as young GP's in a new practice how do we get started?

The first six months we thought how can we make this sustainable? I met with a primary care team for the homeless in London. They seemed to say that if you were struggling with drug and alcohol issues then refer on to the local drug service. But how can we meet the needs of homeless people and not deal with one of the major problems that affect them? Drugs are in the top five health needs.

We developed a strategy and then tried and were reasonably successful in getting support.

Support from professionals, drug teams and other agencies. We had heard already from the network, I cannot over emphasise how important this is. Personally I joined groups and received mentoring.

Financially there is a need to explore the agenda of the provider. What are the potential pitfalls of developing this service? Care not to take part in over or inappropriate prescribing, excessive patient numbers and/or inappropriate involvement with patient that can be projected need, paternalism and/or collusion. Need to watch and prevent burnout.

5.2.4 Shared Care, the GP Perspective - Dr Helen Alpin

I am an inner city GP, and I like being an inner city GP. Those of you who saw the Fergal Kean's programme on Monday evening on "Forgotten Britain" featuring the Lincoln Green area will have gained some insight to into the area and the problems of where I practice. We get over 90% deprivation payments, the health and social problems are vast and an increasing problem is that of drug use. Drug use impacts on us daily from it's effects on individuals, families, increasingly children and not uncommonly in old ladies mugged for their pensions. I have read that approximately 8 per 1,000 are opiate users in the United Kingdom this means for our practice population of about 6,500 we should have about 52 opiate users. This feels like an underestimate, but trying to find more accurate numbers is difficult.

Our care was inconsistent, haphazard we wanted to help but it was causing problems. About 10 years ago we tried our first solution, which was a contract, this was very restrictive and lasted about a week! It simply didn't work. Things went along until the problem was becoming harder to cope with about 5 years ago. We then laid down much clearer principles such as one doctor, routine appointment, notifying the register, using blue scripts, checking urine's etc, and this was working much better.

The Orange Guidelines then came along with the words "...Medical Practitioners should not prescribe in isolation." and "A multidisciplinary approach to treatment is essential." This worried me as I felt that we were vulnerable in our practice and felt that we should now be moving towards this standard of care.

About this time at an LMC meeting I began to tell my colleagues about how little support I felt we got from the Addiction Unit, I was amazed at the response, "We used to feel that, until we started Shared Care, it's wonderful". So feeling a little foolish I began to think about us too looking at developing shared care in the practice. I managed to convince my partners that this could make life better both for us and for the patients and we duly got signed up, with myself going off for the training.

Shared Care is, "The joint management of drug users, shared between general practitioners and a specialist service. Its aim is to, "make the treatment for drug users more accessible and normalised within the health care system."

We have an addiction therapist that is attached to the practice but who for a number of reasons sees our patients in a couple of the community clinics, these are very accessible and acceptable to the clients. All drug users presenting to help are referred across to me and are seen at my next routine appointment usually the next day or two. I do an initial assessment, touching on key areas and then refer by fax containing my basic information to the Addiction Therapist. The therapist then assesses them within 2 weeks and a treatment plan is then agreed. His information, assessment and the treatment agreement is faxed through to me, so I have this when I next see the client. Good communication is a key feature of the success of this arrangement. We both them follow up the client, myself mainly to prescribe but also reinforcing each other's messages.

Looking at the numbers as you can see in the period Oct-April 1999 the numbers have risen about 30% on the same period in the previous 12 months. I am not sure the reason for this. The outcomes as you can see, we have lost about 20%, 20% have failed a detox this may seem disappointing but the National Outcome study suggest that these users have often reduced there risk of harm and the amount of consumption. Taking this along with the 30% on a Methadone script and 13% being assessed I think implies some success of the scheme.

Is it better? Yes, both for clients in getting help from a known source, being able to tackle their other health needs, having a local, more accessible, more comprehensive and faster service. For the doctors less hassle, my increased knowledge and skills, the support of protocols, and working with an Addiction Therapist. The care of this group is now much more consistent. Some acknowledgement need to be made that the scheme is still embryonic and needs further development especially in expanding treatment protocols e.g. use of buprenorphine and expansion of the team expansion of the team especially to help with rehabilitation to "normal life".

However, so far I have little doubt that this scheme has made a significant improvement to our care of drug users.

5.2.5 Shared Care, the Pros & Cons for Users - Alison Hullah, Sean McGrath & Stephen Waddington

Both Alison and myself had been using heroin for 10 years. During that time we both had instances when we felt ready to stop using and therefore approached our GP for help. Thankfully then, our GP prescribed us methadone and sleeping pills.

Unfortunately, due to circumstances, attempts to stabilise our drug use was short-lived. Becoming homeless did not help this. There was no stability or security in our lives; eventually we fell back into the usual circle of junkies. At that time, neither of us could find the incentive needed to turn our lives around.

Alison felt so depressed thinking she had failed. She suffered severe anxiety with panic attacks daily. Each morning waking up to the usual worry of where she was to get any funding for this heroin habit, which was usually through shoplifting and even prostitution.

Then Alison felt that she could not take anymore and cut her wrists! She was not sure if she wanted to die or if all she wanted was a great deal of help, either way she wanted to get away from this hell-hole we called life.

Allison made another attempt to come off heroin, she decided to go to St. Anne's Homeless Team for help but the only option suggested was an immediate detox. Alison had wanted to be prescribed a substitute-like methadone to enable her to build a secure and stable environment.

We both decided to look for hostel accommodation. Although the hostel had residents of both genders, after each of our interviews with the hostel, it was rightly decided that Alison, being a woman was much more vulnerable on the streets and was offered a room, however I was not lucky. We were 2 years into a loving relationship, none the less; we were very dependant on each other.

We knew our relationship could not withstand those circumstances.

We knew we desperately needed to come off heroin, together. We had long-term plans, all of them positive, and shared the same goals. We immediately looked for somewhere of our own to live in. Fortunately we got lucky and before long we were renting our own house. It was clean and suitable, exactly what we wanted and needed. We registered with a GP in the area. This was St. Martins Practice. Our relationship developed so much more, now we could really talk to each other instead of us simply talking about where we could score or how good or bad the 'gear' was. We are able to buy presents for each other.

We have learnt to be much more responsible for ourselves and for our home. We can both definitely say that our self-confidence has improved and self-esteem is not so low now but with lots of love and hard work we are increasingly becoming happier and self-assured.

The Difference Treatment Has Made Stephen Waddington

At this stage I was still heavily addicted to crack so I still needed to find a lot of money daily. Treatment did not really work for me then. It was my Solicitor who put me in touch with a drug project. The drug project he knew about was St Martins Practice and he took me down there to be assessed.

Since I have been in treatment at St Martins Practice, these are the things I feel I have achieved:

  1. I have not committed a crime since beginning this script.
  2. I have stopped using I.V.
  3. I reduced the heroin then stopped using heroin. (I had managed to stop using crack cocaine before I started on a script this time).
  4. I now manage to save money.
  5. I bought my 6-year-old daughter Christmas presents in time for Christmas. Previously I would have resorted to crime to get hold of money for presents.
  6. When I was on drugs I think that I neglected my role as a father - though my daughter was always cared for. Now my daughter is number 1 to me. I take her out and I am interested in her education and development.
  7. I have begun to do work here and there (legally of course!). I have actually got my own van so that I can work.

Things That Have Affected Progress This Time

Though it has taken me some time, I have made more progress this time than ever before, partly because I am growing older and growing 'out' of using drugs.

  1. I used to avoid going to the dentist and often used the pain I felt as an excuse to use.
    After talking to Dr Adams at St. Martins Practice, I realised that I needed to go to the dentist and not continue to put up with the pain.
    Going to the dentist was not nearly as bad as I expected. I am glad I went - for the first time in 10 years I can chew food on the right side of my mouth.
  2. For the first time I am paying off old fines. Before I would not have cared if I had gone to prison.

5.2.6 What can be achieved? St Martins Practice & Treatment Outcomes - Louise Tiffen

A frequently cited reason for General Practitioners not involving themselves in the treatment of people with problem drug use is that this is an area that is short on success. Doctors can feel as though they get little out compared to the effort they put in.

Indeed only last month one doctor spoke in exasperated tones in the press about the selfishness of drug users and the futility of attempting to help them, unless they are prepared first and foremost, to help themselves. According to this doctor, GP's are becoming increasingly reluctant to treat people with drug problems following bad experiences. One GP no longer believes that drug abuse is an illness, but is just an extreme example of utter selfishness.

I and my colleagues would like strongly to contest the view that treating people who have drug problems is not worthwhile, by demonstrating our own work and experience regarding the treatment and management of problem drug use and the identification of treatment outcomes.

Work on the identification of treatment outcomes began at St Martins Practice (SMP) in Leeds, in 1996. What the team has discovered is that we are considerably more successful in terms of managing problem drug use than was anticipated.

In 1996, when I asked the 6 GPs at St Martin's what they would be looking for in terms of gauging someone's progress through treatment, they came up with a list. Of course it would be desirable if everyone treated could become truly abstinent eventually. However the GPs were aware that abstinence was not necessarily a realistic goal for many. As we have heard this morning, it can take multiple attempts at treatment before significant change occurs.

With approximately 60 percent of IV drug users in treatment at the practice testing HCV antibody positive, there were obvious public health implications. At that time the practice had not clearly defined Hepatitis B and C screening protocol, though these have now been developed.

The link between drug use and the incidence of crime is well established. It is also known that crime is reduced among drug users in treatment. Drug users frequently report family breakdown and loss of social support networks. GPs felt strongly that trust should be established early on in the doctor/client relationship. Clients were and are, encouraged to be honest about their drug use.

All these have been considered viable and crucial outcomes by the team equally or probably more important than abstinence.

When the clients themselves were then asked to identify the difference treatment had made to their lives, they mentioned predictable things such as, being on methadone had made their lives less chaotic. For most, criminal activity had ceased during treatment.

The impact upon relationships as a result of treatment however, appeared dramatic. Prior to assessment at the practice, 61% of men and women said that the quality of personal and family relationships were one of their main concerns. Once in treatment this figure dropped to less than 8%.

Over the past three years the clinical team at SMP has developed guidelines for the management of problem drug use clients, which encourage the clinical team and the client to look beyond the immediate drug problem in terms of progress and treatment outcomes.

The client plays an active role in the assessment process and the planning and review of care. This has been fundamental to the ethos of patient centred caring at the practice.

At assessment, baseline information provided by the client is used to map progress and measure outcomes. One of the most important things to note is the exact nature of the client's request. Treatment could fail at an early stage if what is proposed is not based upon the needs of the client. The client is involved in the planning and review of care along with their named GP, addiction therapist and other relevant worker if other agencies are involved with the client. Clients are strongly encouraged to see the same GP in connection with their drug problem.

During 1998 to 1999 there were 67 discharges from the practice's problem drug use treatment scheme. Here is a summary of goals reached or not reached at the time of discharge: 37 client managed to achieve all goals set themselves, 25 had some successes and only 5 failed to reach any of the targets they had set.

What the St Martins Practice team believes this evidence points to, is the people struggling to overcome their drug problem can and do make progress. Factors that affect progress include, the GP's own attitude towards and expectations of the client; having clear guidelines; a consistent approach to practice and involving the client throughout.

The management of problem drug use is no different in many respects to the management other medical problems. The aim is only sometimes cure. Intermediate outcomes such as harm minimisation, social stabilisation, public health issues are the bread and butter of work in general practice. To focus on these reasonable and realistic expectations can lead to a feeling of success and achievement for clinicians and clients alike. Each outcome reached is one more step on the ladder to full resolution of the problem. The climb may be long and hard and involve setbacks, but those who reach the top continually inspire us.

5.3 Public Health & Individual Need - Chair Dr Jenny Keen

5.3.1 Introduction - Dr Susanna Lawrence

[Transcript not available].

5.3.2 The Drug Strategy: How does it meet Health Needs? - Keith Hellawell QPM (UK Anti-Drugs Co-coordinator)

In opening I am not here to accuse you of anything but to congratulate you for the work that you have done in light of what you may have heard from the 'Times' comment.

I was involved in my last job for developing strategy for police services on drugs. In the late 80's we thought there should be a link between all services, all agencies should work together on this common problem. I did ask in Humberside for all agencies to get together but they wouldn't in particular the drugs agencies that felt that sitting round the table with the police would damage their street cred. We have significantly moved on from there.

In the mid 90's I was involved in a Panorama programme and I was accused that I wanted to legalise cannabis. I didn't call for the legalisation of cannabis, but I did say that if cannabis or derivatives could help in a medical situation then I would support this. I also said in that programme that we needed a national network of treatment, that people with drug problems should be able to walk through the front door rather than the back door of the health service. This is a group of people that did not receive proper funding or treatment for their problems. I said that we should recognise this as a real problem and if I had this problem I should not expect to wait for treatment as I should not wait for treatment for anything else.

One of the benefits of this job is having the opportunity to influence. I have the opportunity to influence the government now. Government strategy is not that well known by many people even though the strategy has been out for a couple of years. The woman from the Times who interviewed me yesterday had not read the drug strategy. What I am saying is that many people comment on the strategy but haven't read it. We are trying to get the message across to the drug services what we are doing. The information from the media is not correct. We have got to account for the media agenda. The media regularly inflames people's perception of drug problems.

The strategy firstly says that it is wrong that we are focussing our efforts about dealing with consequences of the problem drug use. 60% of the money is spent on the consequences. We have to stop this shift from dealing with the consequences to dealing with the preventing it happening in the first place with active and intervention treatment.

Education says early counselling and early interventions are what are needed. We need people to be trained and to feel supported in being able to offer the above. Money is and should be directed to helping the most vulnerable groups such as young people, women and their children and underrepresented groups such as ethnic minorities. Half a million pounds has been put aside for dealing with setting up services for vulnerable groups. £100,000 has been put aside for research on vulnerable groups. I have seen some very good fledgling schemes up and down the country dealing with these special needs and money is there to evaluate these services.

We need to provide treatment for disadvantaged groups. We need to have information on what is the unmet need is for especially vulnerable groups. The bid on the spending review is based on this information.

Two and a half years ago I was told that there wasn't any money and there were huge barriers. We are setting up for funding central treatment services. More money has been put in, £50,000,000 for specific drug treatment. Some of this is through the criminal justice system.

I did not have a single equation for general health care. I now have a better idea and will take that to Gordon Brown. Now I am being told there isn't enough people to do the work. How long do we go on? He said that he had concerns that introducing the criminal justice system will skew the drug services already provided. There is traditional instability around funding, i.e. one years funding.

Your concerns raised this morning, I raised 18 months ago. You should have no fears that there is a competition between community-based programmes and the criminal justice system.

I will finish by talking about your own personal positions. I have concerns that within treatment services that we have people working legitimately looking over their shoulder all the time. We need to protect the people that are doing it right.

In terms of training and time - it is going to take time. The end product being abstinence or a reduction of the criminal activities are legitimate outcomes but they are certainly not the only outcomes. It is long road and I have seen 100's schemes and 1000's patients. Shared care is crucial and no single agency can do it. There needs to be a commitment to recognising a range of treatment outcomes and ways of getting there

5.3.3 Questions to Keith Hellawell QPM - Chair Dr Jenny Keen

1) Tom Gilhooly - I want to reinforce the training - the best focus of the money will be training. You will get amazing returns for your money and other GPs will be encouraged.

Answer KH: I agree and money is being put into training. It will take a period of time and I am committed to that.

2) Bill Nelles - I am very glad to hear from the horse's mouth that the gains that we have made from harm reduction are not under threat but I am concerned that we are moving towards zero tolerance - you have often said that you don't want to go down that route and that harm reduction is safe is in your hands.

Answer KH: Yes the drugs strategy is supported by all those who signed it. We listened to lots of people and when Mike Trace and I sat down with the final draft we were told that the government would not sign up to a 10-year strategy but they did. The targets set are not eradication targets and even though we were again told that no one would sign up to, they did. Please do not believe all you read in the papers - we are standing by the drugs strategy.

3) Berry Beaumont - Treatment is essential for people with drug problems - we have concerns that the strategy is trapping people into one particular service. How can you justify this undermining?

Answer KH: In terms of the first spending review we didn't have the information (stats) evidence. I still haven't got a definitive list but I do have a better feel for it and this has been used to base the second spending review. I see community based treatment as the cornerstone of all this. My vision is to provide all the treatment that is required for everyone who needs it, although visions take time.

We acknowledge our thanks to Keith Halliwell for speaking at the conference.

5.3.4 A Review of the Literature: The Evidence for Managing Substance Misuse in Primary Care - Dr Mark Gabbay

WHAT CAN RESEARCH TELL US?

TOPICS:

In this brief overview I hope to address the following topics: why do we need evidence? How do we judge the quality and relevance of what we find? Some of the challenges posed by research in this area. I'll discuss our recently completed systematic evidence review Including our headline results and conclusions, but research alone isn't enough, so I'll touch on issues concerning the dissemination and application of research.

Why bother with research?

So why bother with research, don't we all know what we're doing? We've been trained sadly this forms the basis of much of our training. We're working in areas of clinical controversy and strongly held beliefs and prejudice about what's right and good practice. Research helps solidify our foundations and justify our approaches and efforts.

We need to seek to improve our approaches, and research helps us do that. We should evaluate change: for example, when I worked at the Dept in Manchester, we moved from an ad hoc service with informal links to the local CDT for 40-50 users to a practice-based joint CDT primary care clinic, and were able to do a before and after study. We had to work in limited resources, particularly of time. (Ref: Gabbay MB, Clarke S, Willert E, Esmail A. Shared care methadone clinics-a survey of patient satisfaction, behaviour change and staff views. Addiction Research 1999; 7(2): 129-147.

Assessing Research Evidence

We should all be able to locate and assess research evidence

Keeping up to date this is a challenging field to research, and little of what's been done would be traditionally classed as the highest grade evidence there are accepted and recommended frameworks to aid practitioners in assessing and evaluating research evidence.

Over the past few years the EBM movement has published a number of guides to assessing the quality of evidence. I can recommend this:

The Evidence Based Primary Care Handbook
M Gabbay (Ed), Royal Society of Medicine, Press 1999

Of which this is clearly the best!

Evidence and Guidelines

We are inundated with guidelines. We want to deliver the best interventions and guidelines can help us do that, not only do we need information on effectiveness, but also on what's best for whom and when, but guidelines may be an obstacle to this process if not carefully constructed. As we work in a controversial area, we need to support our assertions and recommendations with the best available evidence. Non-evidence based guidelines can do more harm than good.

Whilst lack of evidence of effectiveness is not the same of evidence of ineffectiveness, when we do have good evidence that something is ineffective, whether absolutely or relatively, we should apply that knowledge to our decision-making. So if we have guidelines, they should be based on the best available evidence, clearly state the strength of evidence underlying their recommendations (with refs) and be amenable to local adaptation (its all in the book)

SECONDARY RESEARCH

Often when we want to find something out, rather than collecting new data, we look to see what's already been done. There are various sources of such information. Some organisations set out to systematically review available evidence, such as the Cochrane collaboration. - Int. collaboration to search for and review research evidence.

I recently searched this database using opiate addiction and treatment search terms and found:

Two systematic reviews, one on naltrexone maintenance, the other on treatments for dual diagnosis, 3 protocols for work in progress on carbamazepine and cocaine, behaviour modification to reduce HIV risk in drug users, and opioid antagonists/adrenergic agonists treatments. There were 3 abstracts of effectiveness reviews: on acupuncture, Methadone v LAAM and methadone maintenance, and 66 trials of treatment for opioid addiction from 1968-1999 in the controlled trials register.

However if somebody else has not already done it, we may need to conduct our own review.

To do this involves a systematic search for the research evidence, and evaluating its quality according to accepted frameworks. Small trials may be combined to form a virtual large trial using a statistical technique called meta-analysis- but this is controversial.

ENHANCING SHARED CARE:
Literature review

I recently led a project that has attempted to systematically review the evidence on drug misuse interventions in community settings. This has been conducted part of Greater Manchester SRB funded project, 'Enhancing Shared Care' which is based at the Trafford Substance Misuse Service.

Our review of treatments for opiate misusers in a primary care setting was constrained by resources (time, staff). Also the difficulty in accessing relevant journals for hand searching, as many drug misuse journals are not included in the standard databases such as Medline, and those that are rarely in university of hospital libraries. Much of the research we reviewed was methodologically challenged, which rendered a formal critical review approach inappropriate.

Furthermore whilst we were doing this Ward, Mattick and Hall published their book, 'Methadone Maintenance Treatment and other opioid replacement therapies - a review of research'.

Our focus was slightly different, and we hope that our respective efforts complement each other.

WHAT WE FOUND

Over the course of 2 years we conducted a systematic literature review, which we have presented as both a literature review incorporating 340 references. The style and quality of the research was very variable (to conduct a formal Cochrane style review). We have also produced a bibliography summarising all 390 we identified.

The methodological challenges, particularly in identifying clear, objective outcomes and compliance issues, mitigates against 'gold standard' RCT type studies that traditionally underpin Cochrane reviews, would have considerably restricted the breadth of our report, and been a lot more expensive.

HEADLINE FINDINGS

I'm going to give you the headlines of our report: Methadone maintenance is effective, more so when combined with other services. 50mg or more is more effective than lower doses in achieving treatment retention and reduced illicit opiate use, but not other illicit drug use. Treatment enhances employment prospects, and there is some evidence in favour of daily dispensing. There's been much less research on methadone reduction programmes, outside inpatient settings, and what there is less favourable than that for maintenance regimes.

We looked at the evidence for alternatives to methadone and there is good evidence to support Buprenorphine maintenance at 8mg or more per day, though there are safety and abuse concerns. There is evidence that it can help reduce cocaine use too. Buprenorphine is at least as good as methadone. Whilst clonidine is effective, its licensed alternative, lofexidine is a better alternative.

Psychotherapy in its broadest sense is effective, but it should be targeted at those with the greatest need. Therefore clients need adequate assessments. The available evidence does not support the assertion that ex-users make the best counsellors. There is little evidence supporting alternative therapies.

EVIDENCE IS NOT ENOUGH

Having the evidence isn't enough!

5.3.5 Final Summary - Chair Dr Jenny Keen

In summing up the conference, Jenny Keen chaired the final drafting of the conference statements in which all delegates participated. She then summed up the overwhelming sense at this conference that primary care treatment of drug users has finally come of age and has moved into the mainstream, with recognised clinical guidelines, an established and developing evidence base, a variety of models, formal support from both the Department of Health and the Home Office and training for practitioners a stated priority. This represented many huge steps forward for primary care treatment of drug users and it was hoped that this would bear fruit in terms of improved services on the ground.

She then thanked the organisers for their tremendous commitment and hard work in organising such a successful conference and looked forward to seeing delegates in Glasgow in 2001.