SMMGP - Substance Misuse Management Good Practice

Substance Misuse Management Good Practice

Supporting good practice in drug and alcohol treatment

Conference Reports & Presentations:
RCGP 6th National Conference (May 2001)

Royal College of General Practitioners (RCGP)

Managing Drug Users in General Practice
Government Drugs Policy & Training
The New Agenda for Primary Care

10-11 May 2001
Hilton Hotel, William Street, Glasgow
Supported by the RCGP and organised by the RCGP HIV Working Party

Conference Report by J-C Barjolin & Dr Chris Ford

Conference Organising Committee

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Conference Organising Committee

Conference Organising Committee
- GLASGOW ORGANISING GROUP
Dr Tom Gilhooly
Dr Richard Watson
- ON-GOING ORGANISING COMMITTEE
Mr Jean-Claude Barjolin
Dr Chris Ford
Dr Berry Beaumont
Dr Judy Bury
Dr Claire Gerada
Dr Jenny Keen
Mr Brian Whitehead

Conference Organisers - RCGP Courses London
Julia Cross
Lisa Liu

Report Editors
Dr Chris Ford
Mr Jean-Claude Barjolin

Rapporteur
Lindi Botha

Educational Grants
Brent, Kensington, Chelsea & Westminster NHS Trust
Ealing, Hounslow & Hammersmith Health Authority
Barking & Havering Health Authority
Lothian Health

Commercial Sponsors
Schering-Plough
Britannia Pharmaceuticals
Martindale Pharmaceuticals
Egton Medical Information Systems
Merck Pharmaceuticals
Altrix Healthcare plc

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1. Foreword

Delegates from across the UK gathered in Glasgow on May 10th and 11th for a conference in the annual series of 'Management of Drug Users in General Practice'. The one-and-a-half-day event hosted by the Royal College of General Practitioners (RCGP) and its HIV Working Party brought together experts and interested individuals from across the UK to discuss the changes in treatment and policy and the role of primary care. The Scottish Drugs Minister, Iain Gray, reviewed Scottish drug policy. He highlighted the importance of harm reduction in the UK backed by central support and funding for services.

Considerable focus was given to recent training developments in both Scotland and England that have given new emphasis to the treatment of patients with drug problems. Development of the RCGP Certificate for Specialised Generalists for England was examined, looking at the curriculum and how this related to broader generalist training developments in Scotland and England. It was acknowledged that generalist training is on the whole more developed in Scotland than in England. However, the RCGP Certificate may serve as a future model for Scottish implementation of specialised generalist training.

The aims of setting up drugs services were examined with examples from parts of the UK such as Dundee and Plymouth. This took into account the increasing role of primary care in influencing and sometimes heading up specialist services. There were also a host of workshops ranging from topics such as managing pregnancy in drug users to the legalisation of cannabis.

The conference made evident the maturing and diverse involvement of primary care in the management of drug users in the practice, within shared care arrangements, and in the delivery of specialist services. The message seems to be that in spite of a number of safety concerns and opting out by some GPs over the past year, more GPs are still choosing to do the work in a specialised and generalist capacity. This is in increasingly diverse approaches and partnerships. Often this involves formal backing by PCG/Ts within local strategic planning through forums such as Shared Care Monitoring Groups. Where the necessary support structures are not in place locally, there are many examples of primary care taking the initiative to develop specialised generalist clinics and shared care support schemes.

There seems to be greater emphasis on 'safer' and more structured generalist involvement. The pioneering approaches of some of our more regular GP delegates seem to have helped build the political backing for wider and more structured generalist involvement. Other factors supporting these trends include:

There was a powerful presentation by Jenny Keen on her research, which demonstrated that many of the circulating fears regarding methadone deaths can in fact be attributed to deaths from heroin, poly-drug use and alcohol use. Overdose deaths do not directly correlate to an increase in prescribed methadone practices. This confirmed the value of treatment in terms of reducing mortality. It also highlighted the merits of good dose initiation, correct and adequate dosing, and a pragmatic patient friendly approach to supervised consumption.

There was an interesting discussion of how the US/global war on drugs affects local treatment policies and outcomes. Also raised was how to best mesh public health approaches with criminal justice agendas.

Dr Tom Gilhooly who has been involved in organising the conference, said: "Primary care is on the threshold of changes which will not only improve services to drug users but also to society as a whole. Do not let anyone doubt that primary care can make a difference"

- With thanks to the editors of the SMMGP Newsletter for this foreword.

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2. Introduction & Background to the Conference

2.1 Introduction to the Conference - Dr Richard Watson

Glasgow was this year's host to the 6th National RCGP Conference: "Government Drugs Policy and Training - the New Agenda for Primary Care". The conference was once again enthusiastically attended by participants from across the UK.

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.

2.1.1 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? The conference in 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. The conference in 1998 focused 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. In 1999, the conference addressed the changes in primary care and how they would affect substance misuse, the new Clinical Guidelines and the broadening of increasing drug problem. Last year's conference, 2000, looked at the many changes that were happening in this field, with the most recent conference of 2001, examining issues relating to government policy and training initiatives and their impact on future drugs users' treatment policies and practises.

2.1.2 Aims of the Conference

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

Organisation and Support

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

2.1.3 Developing the Conference 'Initiative'

2.2 Organisation and Support

Has been given by members of the Conference Committee, the Conference and Course Unit of the RCGP, and the Substance Misuse Management Project.

2.3 Future Activities

2.4 Contact Details for Further Information or Comments

Substance Misuse Management in General Practice (SMMGP)
Trafford Community Drug Team, Chapel Road, Sale, Manchester M33 7FD
Tel 0161 905 1544
E-mail: PCNet@smmgp.demon.co.uk
E-mail: smmgp@freeuk.com
Web site: www.smmgp.org.uk

RCGP Sex, Drugs and HIV Task Group (formerly RCGP HIV WP)
RCGP,14 Princes Gate, Hyde Park, London SW7 1PU.

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3. Consensus Statement 2001

"Primary care is perfectly placed to have an enormous impact on problematic substance use in the UK, including reducing drug-related deaths. In order to achieve this Primary Care, must be properly supported and trained. The resources to provide these on-going supports must be urgently identified and secured."

"The Conference welcomes the statement from Iain Gray, the Deputy Justice Minister in the Scottish Executive, that the Executive supports the concept of Harm Reduction and backs that support with the promise of funding for services for at least 3 years."

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4. Presentations - Day One

4.1 Chair and Welcome Address - Dr Richard Watson

Dr Richard Watson welcomed everyone to the conference, the largest so far. With the establishment of the Department of Health/RCGP certificate and diploma, in conjunction with a university department (yet to be decided) and with the many schemes now paying GPs for responsible care of drug users we are seeing increasing recognition that that this is an area where we can make a massive difference to death rates and to the quality of people's lives.

He hoped that we would have many useful discussions about these developments and related matters.

4.2 New Funded Training for all Doctors - has substance misuse come of Age?

4.2.1 Scotland: where are we with training on substance misuse? - Dr Tom Gilhooly

Focusing in on Scotland, the question is, where does it stand on training on substance misuse? The question is to look at the undergraduate course first. Changes are happening. To look at this question, I wrote to five universities, four of which wrote back (not St. Andrews). It seems that not a lot is going on. Two thirds of the students undergo training on alcohol related issues, which involves typically between 5 and 6 hours across the course.

Glasgow has problem-based learning (PBL), which is important. There is a PBL block in one year. This looks at commonly abused drugs, their mechanisms and effects, the natural history of addiction, adverse health effects, and an awareness of ones own attitudes and the effects of drug misuse on society.

Overall, the chance of influencing undergraduate students is small. There are not enough chances to deal with the commonest misused drugs - e.g. heroin. At a postgraduate level, there is not much happening either. This is the biggest gap in our formal training.

The problem is furthermore that people are not getting help in hospitals. This needs to change.

To talk about Generalist training, what are we talking about? The question is, is it training, or is it information about attitudes and practice? What is it? In Glasgow we have multidisciplinary groups, but it is still lacking. We need to get Generalist training off the ground.

Specialist Generalists - get specialist training and ongoing support.

The question is, does training help?

We looked at 40 patients and their methadone use. Twenty of these patients were being seen by trained staff, and twenty with untrained staff. Of the twenty being seen by trained staff, 80% of the patients were not injecting heroin, whereas 78% of the users seeing non-trained staff. In other words, the sample shows the satisfying results of training staff.

So what does the future hold?

4.2.2 England: DoH plans for specialist generalist (or intermediate practitioner) & generalist training on substance misuse - Dr Claire Gerada

I have been tasked with setting up a certificate for intermediate practitioners and want to look here at a map of the certificate, as it is still in process.

The Royal College of GPs was given £1.8 million to set up a certificate to look into Primary Care and the management of substance abuse. GPs can claim £1000 bursaries to take part in the certificate. Last December applications were taken, and so far we have had 250 (since conference over 400 have applied) people applying. Importantly, we are getting an older age of applicant, and 74% of our applicants have been male, (which fits in with the statistics of the gender division within the industry). Most of the applicants have seen substance misuse, and have not known how to handle it. She was surprised at the response, which goes to show that people are unsupported. Despite the fact that GPs are running these services, 82% of them were untrained. So to address this need, the certificate scheme has been set up.

In total the scheme can cater for 400 applicants at a time.

First of all, we need to identify their learning needs. Up to 90% of the applicants will attend a Master Class, which is held in three centres. The purpose of this part of the course is to get a grounding in the issues. A small percentage of people are automatically exempted from this class, because they have an MSc in substance misuse.

Then each candidate is given a portfolio of tasks and readings to complete. In summary these are:

  1. To clinically appraise clinical guidelines.
  2. Candidates are assigned a mentor, who is there to help them with their tasks. We currently have 20 mentors around England.
  3. Reading material - students are given top papers written in the area.
  4. They move between 8-12 geographical areas, to get together a network.
  5. Masterclasses are given which are based on reading materials. Students are given the opportunity to present papers and discuss related issues.
  6. The Clinical Guidelines are discussed.
  7. Share-care practitioner.

There is a gap of approximately four months between the first and second masterclasses, which will allow the GP to fulfil their learning needs. They are expected to produce material for setting up their own drug service, which includes strategic thinking on its needs. For example, what happens in a needle exchange service? The mentor also assesses the GP, using face-to-face discussions, also examining the GPs consultation skills.

Looking at the time-scale of this certificate - we look to running the first Master Class in November 2001, with completion falling in March 2002. Time is dictated politically, as we will have had to have done a course by April 2002 (before the next financial year).

The moment is here and now for a certificate like this, which is why it is being driven forward.

(Further sheet of information on the certificate included here for reference:)

CERTIFICATE IN THE MANAGEMENT OF DRUG MISUSE IN PRIMARY CARE

1. Background:

1.1 The consequences arising from drug addiction and abuse are increasingly being felt at all levels of society. With the appointment of the 'Drugs Tsar', Keith Halliwell, the government is attempting to tackle these problems with a co-ordinated approach across all areas of government activity. One area where work will be focused is in healthcare delivery, especially in the primary care context.

1.2 GPs and primary healthcare teams are in the 'front-line' in the battle against drug abuse. Drug abusers, their partners and families see the GP as their main point of contact in accessing the health services. The RCGP, together with the General Practitioners' Committee (GPC) of the BMA, recently issued a policy statement calling for GPs and practice teams to provide comprehensive primary care to drug abusers, but calling for training and support for those GPs who provide more specialised services, such as prescribing of methadone.

1.3 Events in the past year, such as the criminal investigations involving GPs who provided higher levels of services to drug abusers, have led to an understandable wariness on the part of primary healthcare workers in developing services in this area. However, the National Plan for the NHS in England promotes the development of specialised-generalist GPs. These will be doctors who develop higher-level skills in specific areas to the benefit of patients and healthcare workers across a PCT locality. Management of drug abuse is one area where acquisition of skills and knowledge might be expected to lead to enhanced services for drug abusers within a relatively short timescale.

2. Scope of the Work:

2.1 The Royal College of General Practitioners (RCGP) is currently developing a Certificate in the Management of Drug Misuse. This will include a bursary scheme for general practitioners (GPs) in England with a special interest in drug misuse who wish to develop their skills in working with drug users.

2.2 The initiative, funded by the Department of Health, reflects the drive to improve general practitioners' responses to working with drug users, acknowledging that for this to happen, adequate training needs to be provided.

2.3 To address the training issue, two courses of study are being developed by the RCGP resulting in Certificate and Diploma level qualifications.

2.4 The Certificate course is designed to cover 5 full days study. There will be 2 or 3 formal training days, depending on previous experience. The remaining 2 to 3 days are for self-directed learning, improving skills through the attainment of professional competencies by field visits and the development of patient care.

2.5 To help enable and encourage general practitioners to undertake the training, the RCGP advertised the availability of a training bursary. Candidates apply direct the RCGP for the bursary to undertake the course. There is no requirement for doctors undertaking this programme to be members of the RCGP. The bursary is for £1000. All costs of the training will be gratis, as are training materials and mentor costs. We are aiming to provide two bursaries per primary care group/trust.

3. Key Aims:

3.1 The three key aims of this training programme are to:

  1. Enable GP's to fulfil the aims of treatment as outlined in the Clinical Guidelines on Drug Misuse.
  2. Develop the role of GPs in local strategic planning and shared care monitoring groups.
  3. Create a cadre of qualified GPs who will improve standards in primary and secondary care.

4. Method:

4.1 An Expert Advisory Group (EAG) has been established by the RCGP. This group is pulling together RCGP members with interest and experience in the field of management of drug abuse. This group has been established within the Clinical and Special Projects Network of the RCGP. The group will meet on a quarterly basis over the duration of the project.

4.2 The EAG is currently devising the core curriculum for specialised-generalist GPs in management of drug misuse.

4.3 The EAG is also drawing together the relevant literature in this field, applicable to the management of drug misusers by GPs in the British system of healthcare.

4.4 The EAG is developing a series of Master Classes in the area of management of drug misuse. These will these will take place in the Autumn. Recruitment of candidates through PCG/ Ts. In some cases, direct applications or applications from Mental Health Trusts will be accepted. Two bursaries per PCG allocated.

4.5 They will take the form of interactive workshops, to be run by members of the EAG, delivered in a 'roadshow' format over the timescale of the project.

4.6 As the specialist-generalists go through their programmes, they will be supported by the RCGP in the following ways:

5. Outcomes:

1. A large group, (around 400), of GPs with higher level skills in the area of management of drug abuse.

2. A small group (the EAG) within the RCGP who will have acquired an extensive body of skills and knowledge related to educational provision in the area of management of drug abuse.

3. A resource centre within the RCGP pulling together the evidence base relating to management of drug abuse in the context of British general practice.

4. Enhanced provision of services to patients who abuse drugs.

5. Support for GPs and primary healthcare teams in that each PCT will be expected to have at least one doctor with higher-level skills in the management of drug abuse.

6. Enhanced professional standing and support for doctors working in this field.

Questions:

1. Why are we using the term Specialist Generalist rather than Generalist?

2. Is there someone looking into nurse practitioners and their training?

Answers:

1. Claire - they are covered separately financially.

2. Claire - yes we are looking into nurse practitioners. It is ongoing and we are trying to find additional funding for them and psychiatrists and pharmacists too.

4.2.2 Developing a core curriculum: what do we need to know? - Dr Gordon Morse

  1. The role of the Intermediate Practitioner: (other names specialised generalists and GP with a special interest)
    - "a continuum of medical practice" between generalist and specialist, which is very broad, so there is a need to be more specific. It is "not prescriptive".
  2. "The Orange Book" Annex 2.
    - Background issues - law statistics etc.
    - The role of shared and primary care.
    - Treatment issues.
    - Prescribing.
    - The roles of other professionals and agencies.
    - Wider health issues - HIV, HCV, harm reduction etc.
  3. Leeds Addiction Unit Diploma in Addiction Studies.
    - Sociology of Alcohol and Drug Use.
    - Public policy.
    - Basic Physiology and Psychopharmacology of Substance Use.
    - Theory and Practice of Addiction Interventions.
    - Psychology of Alcohol and Drug use.
    - Alcohol and Drug Research Methods.
    - The Family and Substance Misuse.
  4. Clouds/KCL Syllabus:
    - Models of addictive behaviour.
    - Models of counselling for addiction problems.
    - Families and addiction.
    - Groups Therapy.
    - Ethical issues.
    - Dual Diagnosis.
    - Assessment and treatment planning in various settings.
  5. NYUMS Syllabus:
    - Pharmacology, epidemiology, social theories, genetic models, behaviour conditioning models.
    - How to access the spectrum of services.
    - Psychodynamic therapies.
    - Dual diagnosis.
    - PTSD, OCD, ADHD, anxiety, depression, eating disorders.
    - Evaluation (assessment) and treatment.
    - www.med.nyu.edu/substanceabuse
  6. Physical/Addiction issues:
    - HIV, HCV.
    - Pregnancy.
    - Dual diagnosis including psychological.
    - Polydrug abuse.
    - The Law (inc. DTTO's).
    - Alcohol (34 000 died from it last year)
  7. Operational:
    - Local and national services and provision.
    - Organisation and development of local services.
    - Contracting and commissioning.
    - Working with and within PCTs, HAs, Social Services.
  8. How it is to be done:
    - Under the aegis of the EAG.
    - "likely to entail an 8-10 day course with some form of assessment".
    - "available through master classes or clinical attachments regionally" (SMMGP).
    - Distance learning?
    - Exchange visits and appraisals?
    - Diploma course to be delivered by "academic partner".
  9. Ideas to the EAG.

4.3 Round Table Discussion

Questions to be asked:

  1. What do GPs need to know to work with drug users?
  2. How can we learn?
  3. What on-going support do we need, and where can we get it?

Summary of the Main Points Raised in the Feedback of the Discussions:

Answers to Question 1:

  1. At an early stage, GPs need to know about drugs and their effects through assessment and listening to the drug user's life-history. At a later stage, more theoretical research and knowledge is necessary.
  2. GPs need to be aware that treatment involves more than merely prescribing. Have knowledge of the laws and of drug markets.
  3. Include all substance misuse information, e.g. alcohol.
  4. Need to be aware of their own limitations and what can be achieved. Be conscious of potential burn-out and attitudes.

Answers to Question 2:

  1. Life-long learning and support is crucial. Look at the outcomes and audit one's own practice. Include patients in assessing treatment success or failure.
  2. Employ a multidisciplinary approach to treatment.
  3. Adapt the National Guidelines to local needs.
  4. Be aware of roles, and be consistent in them.
  5. Manage the chaos.

Answers to Question 3:

  1. GPs need ongoing supervision from mentors both at a local and national level, from other practitioners and also from organisations (including the LMA and PCT) both at an individual and group level.
  2. Local leadership and facilitators are central, including primary care groups. Continue links with statutory and voluntary services.
  3. Embrace reflective learning as a model.

4.4 Questions & Closing Comments & Summing up of the First Day - Dr Richard Watson

Comments and Questions:

Q1: Struck by the fact that "harm reduction" etc. are not prevalent this year. But I heard the term "abstinence". Are we all assuming that we all know about "harm reduction"? What has happened?

Response: we were talking a lot about "multidisciplinary", and that includes "harm reduction" services.

Q2: A question in relation to Clare's presentation - about who applied for this certificate: I learnt on the job and from the drug users. We work with them, and there is an extreme amount you can learn from the people coming to you.

Q3: Question for Clare: What made the Department of Health suddenly focus on the issue of drug misuse?

Response: General sea change over the last few years. I think this group started from Chris Ford's flat in Kentish Town - has driven the agenda. What that did, enabled me to get in post.

This sort of group - and with the fortuitous windfall of money that needed to be spent quickly - This group, in driving that, and being in the right place at the right time, enabled us to say, we have this money and this is what it should be spent on.

Q4 Can I suggest an alternative view, which is that the management of drug users in primary care is a lot cheaper than management through the criminal justice system, and that is probably the reason why the money is coming in our direction.

Response: we can take that cynical view. But it is not significantly cheaper. It is a part of a landscape change in vision.

Comment: come back to the point that Chris made earlier. Making sure that the learning experience was safe both for the user and GP.

Comment: Some concerns with the certificate course - There is some concern that the certificate might become divisive, and that it could be the case that GP felt that they were not qualified or allowed to manage drug users in the surgery if they did not have the certificate. And that if a mistake happened, that they would then become liable or vulnerable. We need to be careful that the certificate is not in itself, or the only way to judge a GPs competence in looking after drug users.

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5. Presentations - Day Two Morning

5.1 Welcome and Introduction - Dr Tom Gilhooly

Welcome to day two of the conference. We are about to hear a presentation by the Iain Gray, the Scottish Deputy Minister for Justice. He will talk about aspects of Scottish drug policy, and explore whether devolution has made a difference to put drugs policy high on the agenda in Scotland.

5.2 Scotland's Drug Strategy: Action in Partnership - Iain Gray (Scottish Deputy Minister for Justice)

Good morning ladies and gentlemen. I am delighted to be here this morning and to have the opportunity of addressing this important national event. It is encouraging to see so many parts of the UK represented here today. And whilst I have been invited here to talk about Scotland's drugs strategy, I will say something about how it fits into the wider UK framework.

There is no doubt in our minds that the work of GPs and primary care teams is crucial to the success of the national drugs strategy. [That said, though, drug misuse can't of course be seen solely as a health issue, its effects clearly impact on all of our lives. And that is why as Tom has indicated, the Scottish Executive has identified tackling drug misuse in Scotland as a priority and the first sign of seeing it as a priority was the creation of a specific Ministerial brief which was given initial to Angus McCay when he was deputy justice minister and then to myself when I took over the job. That is a brief separate from my justice responsibilities specifically because it is seen as one which cuts right across the executive.

Our belief is that it has to do that because it has to mirror what happens in the real world when tackling drug misuse. We have to be able to work across organisational and professional boundaries, and that is as true in the executive as it is out there in the "real world" in Scotland. So to kind of crystallise that effort, I chair a Ministerial Committee on Tackling Drug Misuse, which oversees the implementation of drugs strategy. There is a Health Minister on that Committee, an Education minister a Social Justice Minister and just recently in order to reflect what I see as the increasing importance of trying to create pathways back into training and work for those who have been problem drug misusers and are now stable or trying to live drug free, we have brought one of our Enterprise Ministers onto that Committee as well because they deal with training and pathways into employment. So the Committee, I think, is one of the most successful Ministerial Committees we have set up, overseeing reporting mechanisms, monitoring and partnerships when it comes to our drugs strategy.

The framework is set out in "Tackling Drugs in Scotland: Action in Partnership", launched by Scottish Office Ministers in March 1999, prior to Devolution, but was subsequently adopted by the Executive. Although I was not involved, having met now and spoken to a lot of people who were, I believe that preparation of the document was a good example of partnership in itself in that it was prepared with the support of a wide range of interests, including the Scottish Advisory Committee on Drug Misuse, the Drug Action Team Association, the Convention of Scottish Local Authorities, the health boards, the voluntary sector, health, education and the police.

That strategy was, at least in part, a response to the White Paper of April 1998, "Tackling Drugs to Build a Better Britain". This set out a comprehensive drugs strategy for the UK, underpinned by an integrated approach across Government, with a clear focus on an integrated approach across Government, with a clear focus on achievement. So action in Scotland is taking place within the UK framework established by the White Paper, but with distinctive innovations for the Scottish scene.

To ensure consistency of approach and the sharing of good practice, we have established quarterly meetings between Scottish Executive Ministers, their UK counterparts, and the UK Anti-Drugs Co-ordinator, Keith Hellawell.

"Tackling Drugs in Scotland" is the forward drugs strategy for Scotland. It outlines what needs to be done, sets out the delivery structures and explains how progress will be monitored. A comprehensive programme of action is set out in the document in the form of key objectives and action priorities under the 4 aims, or pillars, of: young people, communities, treatment and availability. The significant thing about these 4 aims is that they are not about single and separate issues that will be dealt with in isolation. They are a set of linked programmes designed to be mutually reinforcing and effective.

For example, the "Treatment" aim - "To enable people with drug problems to overcome them and live healthy and crime-free lives" requires, yes, a significant input from the health service. But the objectives and action priorities require action also by the social work services, the prison service and those responsible for providing employment, training, education and accommodation facilities amongst others.

There are of course, many bodies and organisations in Scotland which are active in drug rehabilitation and treatment. Much of this is hard and demanding work, often with little reward or encouragement, often the reverse. Those being treated often fall back into their old ways, and successes may be few and far between. Even when there are successes, the person concerned may have moved on and the hard-working professional may not see the successful outcome. I am sure this may have been the experience of many of you, but you can be assured that your efforts do not go unrecognised.

The role of Local Health Care Co-operatives is perhaps worth highlighting in Scotland's approach as a good model for partnership working between agencies at a local level. They have an important role in ensuring equity of service provision in primary care, both in terms of strategic planning and delivery of care.

Following on from the Strategy, a year ago we published our Drugs Action Plan which sets out what we are doing directly, and in support of agencies and individuals in the communities affected. In preparing that plan, Ministers looked behind the broad objectives in the strategy and asked what key activities, policies and resources were needed at the centre to support Drug Action Teams and key agencies in turning priorities into action. The document details key objectives, again under the 4 pillars I described earlier, and what we aimed to achieve.

And last December, we announced the first national targets which will enable us to measure progress in achieving key aspects of the strategy. These targets were set following discussion and broad agreement with the drugs field. Finally, as evidence of our absolute commitment to tackling the drugs problem head-on, we tried to answer the question always asked, "where is the money", when in September we injected over the next 3 years, additional resources of drug expenditure amounting to £100 million. In February following extensive consultations on how the extra resources should be deployed, I gave details of the distribution arrangements. In drawing up the arrangements, the Executive also took account of the Social Inclusion, Housing and Voluntary Sector Committee's report on its "Inquiry into Drug Misuse and Deprived Communities", which highlighted the significant links between social deprivation and drug misuse.

Let me briefly run through this unprecedented funding package. Treatment and rehabilitation funding form the bulk of the package. Because without these services, we will never be able to break the cycle of misuse which leads to the many other problems associated with drugs. So from the £100 million, £10 million is committed to treatment services, £21 million to rehabilitation over the next 3 years.

But the package also includes funding across all the other key areas where we need to act on the drugs problem. For example, £18 million for work with our most vulnerable children, £3 million for drugs education in schools, £6.5 million to prepare reforming drug misusers for training and employment, a further £5 million for drugs work by Social Inclusion Partnerships to focus on the known links between drugs misuse and deprivation, and £10 million for developing treatment and through care provision in prisons.

As I say, this package is unprecedented, and not just in terms of the sums involved. For the first time, Drug Action Teams and front line agencies across Scotland are being given a comprehensive 3-year drugs budget, to join up all the critical areas for action. For the first time, DATs are being given a strong say in the way drugs budgets are spent. For the first time, DATs and local agencies will be jointly required to "sign off" plans for the new resources, in combination with existing spending. For the first time, the 3-year drugs budget will allow sensible long term planning. So DATs up and down the country can now work closely with communities in putting together linked programmes of action which will make a real difference.

Of course we are not simply throwing money at the problem. We have also put in place an accountability framework to ensure that funds are directed in support of our national objectives and national targets. We will be monitoring very carefully how DATs and their constituent agencies plan to spend both new and existing resources.

As I have already mentioned, we have set targets by which our progress can be measured. In the treatment area, we are looking to ensure that every Local Health Care Co-operative or Primary Care Trust has a locally approved shared care scheme by 2004. We want to increase the number of drug misusers in contact with drug treatment and care services in Scotland by at least 10% every year until 2005. Relevant drug targets are also included in the new NHS accountability arrangements currently being drawn up. Our new resources for treatment and rehabilitation should realise those targets.

DATs have been asked to set local targets in both of those areas and we will be monitoring progress through DAT Annual Corporate Plans. We have 22 Drug Action Teams in Scotland, many of whom combine other substance misuse topics, particularly alcohol, in their remits. This compares to over 150 DATs in England. The smaller number of DATs in Scotland enables us to have a much closer relationship with them at a local level, and to work with them to tackle the problem. For example, by the end of this month, my predecessor and I will have personally visited all the DATs in Scotland. This has been invaluable, because it has allowed us to hear and see, at first hand, local concerns, local frustrations, and also to set out our expectations. These visits are an essential part of the process of determining the level of new resources for the next 3 years, and where these resources should be targeted.

I think it is vital for Ministers to demonstrate not only that they are listening to, but also supporting, leaders and champions in grass roots communities across Scotland who want to do something about drugs problems in their area. Which is why, last Tuesday, the First Minister and I announced details of a new initiative called "Scottish Communities Against Drugs". The Executive was pleased to match the £500k put up by the Daily Record for the initiative, through which grants will be distributed to community groups to help in making their areas better places in which to live, and to discourage drugs. The funding made available by the Executive will be administered by Scotland Against Drugs and decisions on distribution of grants from either this route or the Daily Record Fund will be taken by the "Scottish Communities Against Drugs" Board. These new resources will help community services to offer mutual support. And ensure that they can deliver what is really needed on the ground.

There is no doubt that we need higher quality and more locally accessible treatment and rehabilitation services. It is vital, therefore, that the additional funding allocated to both health boards and local authorities within the drugs funding package is fully utilised for this purpose. For too long, misusers have drifted or been "referred" from one type of service to another. Our key priority is therefore to develop integrated care, treatment and rehabilitation pathways for individuals. Misusers need to move on from the treatment services to other opportunities and challenges which will bring their lives back together.

From drug misuse - through treatment - through rehabilitation - on to education and training opportunities, and ultimately to a job at the end of the day, which will restore self-esteem, stabilise personal relationships and provide a defence against further temptation and misuse. This is a path that we want to put in place. It is not an easy one, neither for the individual nor for those of us who are trying to facilitate it. The Executive is determined that the drugs strategy is based firmly on "what works". That's why we set up the Effective Interventions Unit. It's also why we have published Scotland's first drugs research programme with a commitment of £2 million over the next 3 years. This programme covers all four pillars of the strategy and is being managed by the Effective Interventions Unit.

This is genuinely exciting development because for the first time research into drug misuse will be co-ordinated across all the different departments of the Executive. The whole purpose of the programme is to make research practical and accessible to the practitioners.

Few of us have the time we would like to keep up with the latest research findings. But this knowledge is crucial if we are to do out jobs better and to get satisfaction from knowing we are getting the best possible results. The Effective Interventions Unit will concentrate on getting the key messages from research out to those who can really make a difference.

We also recognise the importance of information and research to the development of effective service provision. Our Drug Misuse Information Strategy is based on practical information requirements. The Information and Statistics Division of the Common Services Agency - ISD Scotland - is the focal point for drug misuse information in Scotland. It provides information on drug misuse and supporting expertise to the Executive, DATs, service commissioners and deliverers including GPs, the voluntary sector and a range of other information users.

I hope you would agree that we have a coherent, pragmatic drugs strategy backed up by significant resources. But a strategy is only as good as its implementation on the ground. For that we rely heavily on people working across a range of professions within health and social care and within both the statutory and non-statutory sector. In this room today, there is a range of people from the primary care sector - including GPs, pharmacists, nursing staff, and counsellors. This group is key to the success of our strategy. For many drug users you will be the first point of contact. How you deal with them will have a major influence on their subsequent willingness to enter treatment - and to stay in treatment. You will need a whole range of skills - from how to identify that there is a drugs problem to how to handle difficult and even aggressive patients. And that is one of the reasons why training needs to be high on our agenda.

All drug services, of course, rely on a knowledgeable and committed workforce. We need to invest in this area, which is why the Executive recently awarded a substantial contract for training in drugs and alcohol to a consortium of Drugscope and Glasgow University - now called Scottish Training for Drugs and Alcohol or STRADA - to provide training for the next 3 years. Although based at the University, the training will be delivered at as local a level as possible. This will range from short drugs awareness and drugs knowledge courses to longer-term skills training in identification, assessment and intervention. Many of you will be interested to hear that primary care and other frontline staff working in the NHS in Scotland will be one of the priority target groups for the training initiative. Much of the training will be crosscutting but STRADA won't replace more specialist or professional training arrangements. More details about this new development will be available when the resource is officially launched next month.

The role of primary care is also crucial because the demand for GPs, pharmacists and Primary Care Teams to be involved in drug treatment has grown rapidly as the use of methadone prescribing has increased. There is a solid body of evidence that the use of methadone is an effective treatment for opiate users, helping them to improve their health, reduce criminal behaviour and generally improve their life and relationships with family, friends and community. The Executive is not saying that methadone is the only form of treatment that should be provided, nor that it suits the needs of all drug users, simply that we do already have evidence of its beneficial effects in many cases.

But methadone programmes need GPs and pharmacists. I know that among GPs there are mixed views about taking on prescribing for drug users. I also know that a number of you in this room have been in the forefront of the "fight" - and I use that word advisedly - to gain acceptance for methadone prescribing as a legitimate treatment to be delivered in the primary care setting. That, of course, was the reason for establishing these national conferences. I congratulate you on your efforts over these past 6 years and on you success in gaining acceptability for the role of substitute prescribing in primary care. You have also achieved a significant success in influencing the development of training for GPs, which is, of course, the subject of your conference over these 2 days.

In Scotland we now have many more GPs involved in prescribing but we still need more. We also need to look at ways of dispensing and the role of pharmacists in shared care arrangements for drug users. The availability of structures and well-targeted training is going to be vital to encouraging and supporting GPs, pharmacists and other members of the Primary Care Team to become involved.

I know that yesterday you were discussing in some detail the plans in England for GP training at specialist generalist level. We in Scotland are very much aware of the Department of Health plans for new training courses which are now being taken forward by an Expert Advisory Group. We are watching these developments carefully. But at the same time we are examining with Tom and some of his colleagues where we should be focusing our efforts in Scotland. There is clearly considerable interest in the development of a Certificate for specialist generalists and we have that under active consideration. However, our discussions so far lead us to think that the first priority is to develop a consistent model for generalist training. The current levels of service provision, geography and population distribution in Scotland indicate that this is the greater need.

Following recent meetings between the Shared Care Scotland Network and the Health Department, we will be taking forward the idea of a set of core competencies for GPs and the Primary Care Team. We will also be encouraging discussions between STRADA and the primary care sector on how training might be developed to match their needs. There is no doubt in my mind that there is added value in multi-disciplinary training, in terms of promoting a more integrated service for drug users.

The big challenge for GPs, pharmacists and Primary Care Teams is how to work together effectively and how to work effectively with other professionals. Currently, we use the term "shared care" to describe these kind of arrangements. The Scottish Executive is keen to see the shared care model operating across all parts of Scotland. To underpin that commitment we have, as I mentioned earlier, set a national standard that all Local Healthcare Co-operative areas should have a shared care scheme in operation by 2004. We know at the moment that shared care is being delivered in most parts of Scotland. 20 out of our 22 Drug Action Teams have some degree of shared care operating in their area. But we also know that there is considerable variation on how such schemes operate, with some being limited only to an arrangement between GP and pharmacist. We want to develop and promote a model that sets out the core elements of shared care to underpin the arrangements across Scotland.

I am pleased to say that out Effective Interventions Unit, which was set up last year to identify and support development of effective practice, is taking forward a major piece of work in this area. In February, the Unit issued "Initial Guidance on Shared Care Arrangements for Drug Users". This was only the start of a larger piece of work, which ultimately, is designed to promote the development of integrated care services within an overall community care framework. Integrated services need to take into account the full range of agencies which have a part to play in the treatment, care and rehabilitation of the individual. The role of GPs, pharmacists and Primary Care Teams will be an integral and vital part of this wider model. But we firmly believe that we need to have good arrangements in place for helping drug users get access to other services and other opportunities. Sometimes this may be in conjunction with treatment where an individual needs help with Housing or Benefits issues. On other occasions the issue may be how to help the individual get access to opportunities for training and employment.

The Effective Interventions Unit is going about this work in an open and consultative fashion. Some of you may have been at the 5 seminars which they held in March and April to test out reactions to the initial guidance and to stimulate ideas on how to take this forward. A report from those seminars will be available soon. I know others here, including Tom, are on the Development Group which is supporting the Unit's work. Not surprisingly, training for GPs, pharmacists and other healthcare professional has already been raised as a major issue.

I believe that this is an exciting time for those of us engaged in the implementation of the Drug Strategy in Scotland. There is a real opportunity for us to make a telling, and lasting impact on the drugs problem. We have additional resources. Perhaps arguably not enough, but certainly more than we have ever had before. We have an improved employment situation where tackling the difficult issues perhaps get filtered back into training and into employment become more possible than previously. We do have a wider acceptance of approaching substitute prescribing than we did have before. So the opportunity is an enormous one.

We can train GPs and pharmacists until they are all completely trained out. What we need as well from health professionals in this field is commitment, and that is a kind of relentless, thankless, and sometimes it may feel, pointless commitment which absolutely has to underpin the work that you are involved in. At heart what lies under the strategy of the Scottish Executive to drug misuse is a determination: firstly a determination never to give up on the enforcement side of this issue, never giving up on trying to stop the dealers, trying to stop the traffickers, trying to stop the flow of illegal drugs into Scotland. But also, mirroring that with a determination never ever to give up on helping those who become involved in drug misuse. Because we ought to understand that in Scotland these are our sons and daughters. We will never ever give up trying to provide the opportunity to support them as they try to move away from drug misuse.

I am conscious that they are your patients too, and I guess not the easiest of patients for sure. So I finish with a plea, which is never to give up on these patients. I want to thank you for the work of these two days. I hope that you will have a productive day and I am sure that the outcomes of the discussions from both days of your conference will feed back into developments in training in Scotland. Thank you.

Questions to Minister:

  1. I wonder if you think that the public's perception of drug users is improving?
  2. As Scotland has its own parliament now, don't you think that Scotland should have its own drug Tsar, someone who has a clear insight, not only of the needs of the service users, but the needs of the GPs, the needs of addiction teams who are working on the frontline?
  3. I am concerned about the Daily Record campaign - the emphasis is on exclusion and punishment of drug users, not on treatment. The best way to help communities and families is to make treatment available for all drug users.
  4. Money should follow patients. Glasgow has the worst drug problem by far, and a higher proportion of the money should go to deprived areas, which is not the case at the moment.
  5. Minister I am delighted that you have told us about the money. I am also delighted to hear you publicly talking about substitute prescribing and its importance. Here in the conference we are all aware that our underlining philosophy is harm reduction. Yes, we do get some people out into rehabilitation, but the vast majority of drug users need a harm reduction approach, using substitute prescription and support. While I would appreciate the 3 years of funding, harm reduction has to go on for a lot longer than three years in order to get people through that cycle and into rehabilitation. Though what I would like to hear from you, is your view on harm reduction, and some thoughts (I know it is impossible for any government to commit money beyond three years), on how we can be confident that this money will continue long enough for us to continue our work in harm reduction.

Answers:

The first question and the last relate quite closely. So I will start with the first and end with the last. The image of drug users improving: I think the understanding of the issue is improving, and one of the reasons for that, I think, is that there is a wide perception out there that drug misuse is something that can affect everybody. There are very few families, I would think, who don't know someone or know of a family who have been seriously affected by the issue. And I think that perhaps the smugness of some of the better-off communities in Scotland that this was something which happened in another country really, I think that has changed. It is not perhaps quite as realistic as it might be, but it is certainly different. And I think that the distinction between the criminal side of the drugs industry and the victims side of the drugs industry is more clearly and widely understood and accepted now, than it was 5 or 10 years ago. That is my impression. And to jump a question, I think that one of the indications of that, curiously, is the tone of the Daily Record campaign.

I will be quite honest with you; I think that part of the Daily Record campaign was their "shot the dealer" campaign, where people were to phone up, and where they published names and addresses of those who they believed to be drug dealers. That was a difficult aspect of the campaign for a deputy minister for justice to support, because clearly my position is that if someone has information about a crime, then they should report that to the police, that would be the police's position as well. But I think that if you are not a Daily Record reader, well my position is that you have to be a Daily Record reader, and if you go back and look through the campaign, one of the things that struck me very strongly, and which allowed me to be supportive of the Daily Record campaign, without explicitly supporting the "shot the dealer" aspect of it, was that from the very beginning it made a very clear distinction between those who were victims of the drugs industry and those who were part of the mechanism, the promotional part and so on.

Now where they drew that line, I think, is something that this group would have an interest in debating, because of the relationship between small-scale drug dealing and using. Nonetheless, a significant aspect of their campaign from the beginning was to demand better accessibility to treatment and rehabilitation services for those who had been involved in drug misuse. And that is why I felt that it was both right and possible to work with them, to actually take that aspect of their campaign on to a different approach, which is where the idea of "Scottish Communities Against Drugs" and the two funds came.

So I think it is worth looking at that campaign, because it may not actually have set the tone that a first glance would suggest. Now I think that the Daily Record is a newspaper, and it has to have some license over what its readers will accept, and the fact that they were able to make that distinction and say that to them, is an indication, that in particular in the communities most badly affected by wide drugs misuse, there is an understanding of the fact that it is their own neighbours and family who are victims of drugs misuse. I hope that is the case.

In terms of a Drug Tsar for Scotland, my predecessor Angus McCay when he was given this job, used to be called the Drug Tsar, which drove him crazy. I have never been called the Drug Tsar for Scotland. I do not know if this was because there is something less regal about my demeanour than Angus McCay's. Or whether the press have understood, and this is the important point, that the Drug Tsar, (or Drugs Co-ordinator) is a UK position. And so Scotland does have a Drug Tsar, and that is Keith Hellawell. That is his role, and that is why we meet with him on a regular basis. I think that is a strength and the reason it is a strength is that his remit cuts across all aspects of anti-drugs work and that includes enforcement. There are significant areas of this brief which are reserved to do with trafficking, Customs and Excise and so on. I think that the set-up that we have makes good sense. It is incumbent on me in particular and the Executive in general though, to ensure that our relationship with the UK bodies and appointments such as Keith, work well. And indeed in the Scottish Advisory Committee on Drugs Misuse, and I can see some familiar faces, you will know that this is true. We have recently had a discussion about that and are working to try and improve our relationships with, for example, the ACND, so that we are working closely together.

The last question was about harm reduction - my view and the long term.

My view is fairly straightforward. In this area harm reduction is probably the only thing that we have solid demonstrable evidence that it works and really makes a difference. I am quite prepared to make that argument under difficult circumstances. And I do, in my constituency, there is a very small pharmacy with a very large number of people collecting methadone scripts everyday. The local community are not happy about it. And I have and I am prepared to say to them, that even at the basis level, that in terms of a reduction in drug related crime in their area, this is the one thing that we know will make a difference. So I am prepared to make that argument.

I think beyond that we have to keep an open mind. You asked a question about the view of harm reduction, and where it leads. I am happy to accept the view that it is better for somebody to be stable than not, but I also think that I have to say that what is incumbent on us is to provide as many opportunities and possibilities as we possibly can for that stability to then lead on to a life which is drug free. But I don't see that as a second order. One of the issues I think, around access to training and particularly employment, is that we need to do more to get employment services and employers themselves to accept that somebody who is and has been stable for a long time on a harm reduction programme, is somebody that they should consider as an employee. And that to make the demand that they will only employ drug users if they can prove they are drug free, is simply to undermine the potential for creating an integrated pathway. So all of those arguments I am happy to make. I have made them on television as Tom knows. Sometimes they can be difficult.

How long will the resources go on for? I don't know, I have to tell you. I probably should not do this, but I can't tell you beyond the next 4 weeks, because the resources which we have committed for the next 3 years, do depend on the understanding that we of the resources will be available to the Scottish Executive. And were there to be a change in the Westminster government, that could well change. But certainly, if we are safe with the resources that we already have, then that is the minimum resource which will be available over the next 3 years, the minimum resource. Beyond three years, I don't know.

But here is the key; the key is demonstrating that the projects and the work that you undertake are making a difference and work. If we can do that, then when the three years is up, then to remove those resources would be an incredibly difficult decision for a politician, whoever that politician was, to make. Secondly, if we strengthen the Drugs Action Teams, and your voice in those Drug Action Teams, that will also be an enormously strong local political voice, which again in three years from now it would be difficult for a national politician to close his or her ears to.

So, three years is all I can really offer, but if we make them work, then I think that has the potential for the future.

Chair's Summing Up:

Thank you Iain Gray. It is tremendous to get so much support from government. I do echo again the view from the floor that harm reduction is the way forward, and it is very encouraging that we have a department called the Effective Interventions Unit. I mean just the name of it, is encouraging.

5.3 The tale of two places - what are our aims when setting up a drug service?

5.3.1 Chair's Introduction

In the next session, we are going to look at two places. One, Dundee (in the shadow of Glasgow - Glasgow always hogs all the publicity, quietly and very effectively), Andy was involved in that as a GP facilitator, set up a system there which is quite comprehensive. It has very good training and very good support, and you don't hear very much about it. To be perfectly honest, I did not know much about it until Andy Rome told me in a meeting. It is a good idea to shine the light on some of these other areas where there is very good work going on.

Following that, we have Hugh Campbell. Hugh is going to talk to us about a very different set up in Plymouth. Hugh has a very interesting approach, using psycho-dynamics, and psycho-therapeutics which are very much worth hearing about.

5.3.2 Dundee - Andy Rome

I would like to talk about the scheme which covers Tayside - it brings together the work that was done by drug practitioners and the work that was done by a long-established drug service.

Dundee City is the largest city in Tayside. It is famous as being the home of Desperate Dan and Dennis the Menace. It is also been called Europe's answer to San Francisco. This was not my description, but I read this somewhere in a glossy magazine about coming to visit Scotland somewhere. We do have two bridges. It is a great tourist attraction.

Nowadays, Dundee has a different profile. Looking at the period between1994-9, in the city itself, there are estimated to be 1200 injecting drug users. HIV prevalence rates amongst injecting drug users, was estimated at about 30%. To put that in context, the average rate of infection amongst IV drug users in this country was thought to be at about 10 - 12%. Edinburgh was at 25%, and the only other European city showing 30% was Madrid.

Injecting prevalence rates amongst males was 1.67% which was higher than any other area in the country at the time. So the combination of these factors, with HIV, made the development of the drug services a huge issue.

In 1994 I was working with drug services, as a charge nurse, a key worker. At that time we had a waiting list, which was over a 100 people at any one time. At times, which was an ugly thing to do, we had to prioritise injecting drug users, pregnant users, users out of prisons, who should get prescriptions and who shouldn't. So these were very difficult and stressful times, and not only for us in essential services, but also for GPs, many of whom were prescribing for people with drug problems, but who could not access our services when they needed it. The irony of it was that we were dealing with very chaotic people, but because we could not operate a system which could accommodate these. So the situation was that we were dealing with the more stable clients, and couldn't get them back to their GPs, and they (the GPs) were dealing with the chaotic clients and couldn't get them to us. So the situation was very difficult and became logjammed at both connections. That challenged our philosophy of harm reduction that was to be able to provide these services especially in a climate of HIV infection.

There were several reports which emerged and which we found supportive. These included the "Drug Use in Scotland" Report, which said that Tayside Health Care Strategy had to provide substitute prescribing from a central facility.

The client list has now reached saturation point. At this point, it was easy to get into siege mentality, which probably we did. We were really encouraged to see the finger being pointed at GPs, as the ones who were at fault.

The Second report, a Scotland-wide report, saw the role of the GP as central, and not as merely transferring responsibility to drug services and again it talked about partnership approach as the way forward. So we were beginning to feel that there was something here that backed up what we were saying.

The Tayside Drug Liaison Committee was a group, which preceded the drug action team, and was similar in its make-up and its remit. Looking at all factors, they concluded that GPs should play a major role in strengthening individuals, but that they should be supported. Part of that support was to be a GP facilitator, which is a role I came into - appointed to provide training and support, and liaison.

The subtext to that was to get GPs prescribing.

My strategy - which in hindsight was perhaps not the best way to do it - I have called the Mad Fool approach.

The approach was the Neville Chamberlain approach, which was to have a piece of paper in my hand and saying "here I have my answers, it is you that is at fault, and you are going to have to change the way that you do things".

My life insurance was not fully paid up, so it was really the wrong thing to do, to walk into the GPs surgeries, waving this piece of paper, saying, "change".

I was oblivious to the impending danger.

So the next part is called, "how to take constructive criticism".

It opened up a dialogue. Before I think we were moving parallel to each other, now we were talking to each other. It helped to clarify the whole position and my employment. And it helped us to get a balanced perspective, and gave me the other point of view, which I had not had.

It changed the whole emphasis of my role and the way that I went about achieving it.

So Plan B emerged and I went to see my own GP. Not through stress, but because he is a nice guy, and I wanted to talk to GPs and hear what they were saying. So, do your homework, find out how GPs operate. That was one of the best pieces of advice I have ever had. And don't judge a man until you have walked away in his moccasins!

So the problems that we established:

Over the next few months I visited 72 of the 78 practices in Tayside. And the approach that we took was to sit down and ask, does this practice do any prescribing, if yes, what are the problems, and if not, why not. Some of them were quite honest, and said well, this practice does not see any drug users. Which is fair enough. But there were others who said, they did not do it because they had had problems in the past and we don't have the support. So it was a very useful exercise in being able to establish what the needs were. Many GPs felt that this was not a part of their job.

Needs were: education for GPs and faster and more efficient communication between the GPs and essential services. Now working there, I had always thought that we communicated very well. But what GPs were saying was that because the keyworker allocation was by home postcode, a patient working in the centre of the Tay would be allocated to the keyworker with the TD1 postcode. Now that person would have a practice out of town, would have to deal with 8 or 9 different keyworkers about different clients. So, although we thought that we were being clear about what we were saying, the GPs were saying, who are you and where do you work. The tone of the conversation would be, you have got a new client on your lists, you will not have received his casenotes yet, because he has just got off of his last GP's list. Will you prescribe him x, and fully expecting the GP to say, yes, I will do that. So there was a need for better and faster communication and total support in this work.

Solutions:

So what we looked at providing was training and education packages for all primary staff. But also looking at the role of practice nurses, the role of the front desk staff - what they needed in terms of support, and what they needed to know, and development workers. Much of which we took from an established package of training from Lothian.

We tried to look around at different models from this country and different countries, and to pick and choose what we thought would best for Tayside.

We allocated keyworkers to practices, so that each practice would have one keyworker. Virtually overnight waiting lists were reduced. We were able to get 2 more staff, and by doing that, reorganised their working and managed to clear the backlog.

The other solution was to provide additional funding. This was about new resources, which was harder to find.

We put together a 3-year training programme. We had 4 courses, 2 for GPs where we saw the need for a general training and for a specialist training as well. We also saw the need for nursing staff training and for reception staff.

We aimed to deliver it as locally as possible, for Tayside. Dr. Laura Freedman and myself did that delivery. That ranged from half day to full day meetings, to one practice, which was dealing with 2 drug users, where Laura and myself spent 4 whole days there with all the staff, because that was what the need was. So it was not to do with those with the most drug users needing the most training, it was about identifying where the need was, and how big the need was and filling that gap.

Building connections between the surgeries, we saw as crucial. Both in terms of communication and in terms of supporting the GPs. Being able to sit down with their GPs and being able to say, "the person you sent to us last week, he never turned up, and I need to talk to you about this person", was far more valuable than letters flying backwards and forwards.

A regular newsletter to the GPs was an idea that we had at the start, but we found that it wasn't a great idea, because it made another flyer on the GP desk. What we found more appropriate was to use existing newsletter from the Health Board, and when there was something to say, put it with that. It was an established newsletter that GPs had.

The GPs needed access to GP facilitators. What we needed to be able to do was if a practice phoned up and said, we have a drug problem, we needed to be able to say meet in a couple of hours, rather than in a weeks time. As well as cutting down the waiting lists, we needed to have a rapid access service. Trying to work as flexibly as possible to meet the needs of each practice and offer support.

If there were problems, we needed to be able to act quickly and efficiently.

We managed to get a leap of faith agreement from most GPs that they would do this, on condition that these things were forthcoming. That worked. But what we then had was a cohesive scheme, we had a scheme which was based on goodwill which I did not feel to be long-lasting. So we needed to find additional funding to provide remuneration for non-GMS.

We needed to have a backbone to good practice, and a protocol to support that.

We needed a system where we could pick up on problems as they arose and changing trends, and be more proactive in the drug services, having been reactive for a number of years.

We needed to move to a system where we were not asking GPs to come out for an evening in the cold and the snow for a meeting. It was far more effective when we went to the practice to do out work.

All the support was tailored to the needs of the individual practices.

The remuneration was by attendance. So whenever a GP saw a person they would be remunerated for that. We felt that was far more equitable. So for a GP who was seeing 1 person 26 times a year would get paid 26 times for that, rather than a one-off lump sum.

All patients are assessed by their keyworkers, the GPs do not do this. This is one tool that is used throughout the region, so that everything is measured against that tool. So that if a patient moves to a different practice, the GP can pick up their treatment in the same point. All patients are reviewed every 6 months at least, by their keyworker, with that information being fed back to each practice.

Within the Tayside area, 96% of patients on methadone are seen within the scheme.

We looked at each practice, and compiled a practice profile and an audit for each person in the practice, e.g. GP, pharmacist, nurse, etc., and ask what their needs are in terms of learning, what their needs are in terms of support and communication. So we can also look at a locality and see what the needs are.

GP Involvement:

It is essential that GPs should be well represented strategically in the plan of the care that is delivered, so there are going to be more people pointed towards treatment. We need to ensure that you will have a say in saying that more treatment means more resources.

If I can end this presentation on a downer: The difficulty is that we have not had that representation which has allowed us to make use of every resource. So in fact the resources have been reducing in the Tayside area, which means that we are starting to see waiting lists again in the city and in the area again. It must be that the resources follow changes in working practice particularly successful ones.

5.3.3 Plymouth - Hugh Campbell

The subject I have been asked to address, is what should one's aims be when setting up a drug service. I am not going to give a direct answer to that question. What I am going to do is provide some observations from my own experience and experiences from the Plymouth drug services, in the hope that it may give you some thoughts and ideas to stimulate discussion.

Plymouth is on the Devon-Cornwall boundary with a population of about 1/4 million. It is an interesting place, in that it is near the sea and near the moor. It is a very deprived place. If you compare the pathology morbidity for cancer and heart disease, it is very similar to that of a northern city. It has a large drug problem. One of my gripes is that there has never been a proper needs assessment. My own view is that a needs assessment is an essential starting point if one is planning a service. There are about 1000 IV drug users in the Plymouth area.

A brief synopsis of the history of Plymouth drug services:

It was the first service to open a 12-step rehab place, started in the mid 80's. The first major step forward was the creation of the statutory agency, the Plymouth Community Drug Service, as well as the non-statutory agency, the Harbour Centre. It was at about that time that I became involved in share-care arrangements. Things worked well, and we began to see that as a problem in terms of the large workload that we might incur.

Another rehab place called Trevi House opened in the early 1990's. It was for single mothers, or women with problems with drug misuse. Things went well for 8 years. However, problems developed from 1995 onwards, which culminated in an enquiry last year, into the working of the Community Drug Service. This was because of the amount of discontent that there was. The present situation is that the drug services are in a moment of transition, and there are plans for a merger between the non-statutory and statutory agencies - also the agency which deals with referrals for rehab and alcohol services.

As I said, things worked well and I became increasingly involved. I remember seeing an article by Clare Gerada, and a phrase caught my eye. She talked about treating drug misusers as any other patients, and this proved to be my experience. In 1997, a researcher from Exeter University approached me, to look at the prevalence within the Plymouth area, mental illness, we came up with these figures.

So there was a group of about 500 people with problems.

The overlap between all three areas was remarkable small, which surprised me.

Survey into GP attitudes:

As I said, things started to get difficult by about 1995. The Plymouth PCG arranged for a very simple survey of GP attitudes. This was a survey of 151 GPs, of which 79 replied.

The first question was: Do you feel that primary care has a role in the treatment of drug misusers?

A large number felt that there was a role in primary care for drug misusers, a small number did not. I guess that partly reflected the number who were already involved at that point in substitute medication, which was about 35% of all the GPs in the Plymouth area. A significant number actually prescribed substitute medication - we did not ask whether that was of the order of independent prescribing, or within shared care.

What was slightly shocking was a very simple analysis of what prescriptions were being issued. At this time I was doing a diploma at St. George's in London, and realised that there are different views about what is an appropriate substitute medication. The local services seemed to have an extreme view. Particularly worrying is the numbers who were prescribing both benzodiazopines and methadone - and that is a situation that continues today. There was also quite a penchant for prescribing amphetamines.

I was surprised by how many had actually looked at the government guidelines - but of course we could not ascertain in how much detail this had been done, or whether they had just opened and closed them again. There was some degree of ambivalence about the prescribing policies of the local drug services. There are a startling number of people who are not happy with the local provision of services, and particularly to do with accessibility to those services.

Looking at training and support needs - again there was some degree of ambivalence about training, some arguing that they did not need training. A large number felt that they needed additional support, and a large number that they needed additional remuneration for the work that they were doing. Against a context in which there was increasing concern about the activity of the statutory agency and the non-statutory agency.

One colleague in the Torbay area went to the National LMC conference and had this particular motion:

"The conference believes that in the view of recent events, GPs should no longer prescribe opiate substitute medication unless the following 4 things are in place:

The effect of this document was that almost over-night, about 50 GPs stopped their substitute prescribing. They certainly now felt they were in a very exposed position.

The LMC motion had negative effects. There is a factor of negativity around GPs at this time, thinking about the adverse publicity around the Harold Shipman affair. There have been some high-profile methadone deaths relating to GPs. We also have a local coroner who is very keen to expose bad practice, and for those GPs are not very comfortable in this area, that obviously makes it a very adverse problem. The current situation in Plymouth is that if a GP has a methadone death, the coroner has said that he will subpoena him to give evidence in court.

At the present time, there is no local training. There is relatively little professional or financial support. There is no facility for supervised consumption. The Community Drug Service has suffered problem after problem, to the point now where it is quite a small service.

What would I like to see put in place in the Plymouth area:

At the moment the service is very focused towards the adult mental health service. I would like to see a more holistic approach, which is an approach that I call a psychosocial perspective. It should focus on the needs of both the clients coming in to the service, and also primary care needs. At the present time there are sometimes 3 or 4 different assessment pathways into care, and I think that it would be more useful to have a single needs assessment. Increasing multidisciplinary input with extra networking would be helpful and far higher accessibility to the services and much better links to secondary care.

I would like to see the service embrace other areas such as alcohol. This is debateable, but also involving other substance abuse, such as eating disorders. It is critical to embrace a range of philosophies, not just in terms of abstinence and harm reduction, but psychological approaches as well. An adherence to evidence base, and the freedom to explore other avenues of treatment safely. A clear interface with the mental health service.

5.3.4 Chair's Summary & Introduction to next paper - Dr Tom Gilhooly

These are some sobering thoughts. To see what has happened in Plymouth, we must, as Hugh has said, fight to defend our services. Part of the function of this conference is to give people support, to network and to make sure that in areas where there are problems, that we can encourage them, and give them some real and meaningful support and integration with other areas.

Now to the next presentation. Jenny Keen will give us some insight into drug-related deaths. This is very important moving on from some of the problems Hugh mentions, Jenny was a GP until 1988 in Sheffield. She now works in a service which encourages Primary care involvement.

5.4 Drug related deaths: how can primary care help to reduce them? - Dr Jenny Keen

Jenny Keen used to be a GP principal in Sheffield, now works exclusively with drug users.

I was very interested to hear the last speaker and what has happened in Plymouth, because a few years ago in Sheffield we were in a very similar position. We had the LMC against us, we had a local GP who had problems with a script that had gone wrong. We generally started with a low base line. I think it is fair to say that in some ways we have managed to turn things around.

In 1999 I became involved in setting up a completely new service for drug users in Sheffield. This was a primary care service for drug dependent people and was primarily designed as a methadone service, because that was where the need was perceived to be greatest. Since 1999, over the past 2 years, we have taken new untreated patients into treatment, so that we now have around 400 patients in our service. We all know the evidence about methadone, and we all know that it has good harm minimisation effects. We all know that it can reduce illicit drug use, risk-taking behaviour, it can reduce among heroin users, and the drive to criminality. But as prescribers, I know that what many of us fear is that some of that methadone that we are prescribing can end up contributing to somebody's death. We can't get away from that underlying fear.

I am in a very fortunate position in that I also work as a research fellow at the University of Sheffield, researching into heroin use. Sheffield Health commissioned me together with a team at the university, to undertake research into drug deaths in Sheffield. I hope that as can be seen in my presentation here today, that even in a relatively new service, where many of the people providing the service are relatively new and inexperienced, methadone can be prescribed safely and effectively and that there is an important role for primary care in reducing and preventing drug related deaths.

Background:

Through the 1990's worldwide, drug related deaths have been rising gradually. This is both from acute causes, which are drug toxicity deaths, and chronic causes, which has come to refer to HIV, but I think that the time-bomb we are sitting on is Hepatitis C. This is a serious public health problem. A young heroin injector is at 14 times higher risk of death than a non-drug user. In Sheffield, acute drug-related deaths doubled between 1997 and 1998, but fell again in 2000. We were asked about why this had happened. What had gone on?

Possible Explanations: research commissioned to investigate causes:

We thought of some possible explanations to explain this. We managed to rule out natural variation as a possibility as there was significant deviation from the trend of the years previous to this period. We wondered whether there had simply been a concurrent increase or decrease in the drug using population in Sheffield. But as you will see from the demographics later on, this is very unlikely to have been the case. We also wondered about questions of drug purity, and liased with the police and coroner on this issue. Looking at drug seizures over these years, the drug purity remained at roughly the same level.

So we are left with two possible explanations. One was that there was some trend in the characteristics or circumstances of fatal overdoses that might have affected deaths. The other was whether availability of drug services, or the practices of those drug services might have had some contribution.

Clinical Developments in Sheffield 1997-2000

Indeed over these 4 years there were some very major clinical developments in drug services in Sheffield. There was a low baseline for all treatment services. Sheffield is a large city, and we suspect that we have about 5,000 injecting heroin users. Drug services in the city have historically been underfunded. In 1998 there was a waiting list for methadone maintenance of 180 patients who were waiting for more than 2 years. There was an overstretched consultant service, working under siege. There were a few very dedicated GPs, very isolated, working with no protocols, but doing their best in a serious situation.

In April 1999 we opened a Primary Care Clinic for Drug Dependence. The idea of this was not to take away from GPs the responsibility that we perceive GPs to have in looking after their own patients. The idea was to offer a GP led service in an area where the baseline was so low, and there was so little support or shared care, so that GPs could feel that they could phone in and discuss things with us and that they were amongst peers. We targeted an older group of users requiring methadone maintenance. These were not candidates for a quick detox. We recruited 200 previously untreated patients in our first year to the clinic. In the second year we recruited a further 100 patients, and we now have nearly 400 patients.

At the same time, the numbers of other GPs prescribing methadone in the city, doubled. I think that was partly due to our efforts. We worked very hard to involve GPs in this work and to help them to be confident. It was also because of the National Guidelines, which had been released early in 1999, which gave them a defensible method of practice. Overall in Sheffield, methadone maintenance patients in treatment doubled between the years 1999-2000.

Clinical Protocol:

We were very aware in doing this, that in taking on this number of previously untreated patients so quickly, we needed to be very careful. We needed to maintain the confidence of the GPs, the safety of the patients, and the safety and confidence of the general public. So we based ourselves very firmly on the National Guidelines. This meant that from the start, we saw the need for a closely integrated pharmacy scheme, which did not previously exist and which, I believe, that Glasgow has had for a long time already. We arranged that a central pharmacy would liase with a lot of the other pharmacies, such that any GP in the city can now get access to supervised methadone dispensing, if they so wish. They can get access to them every day of the year.

The effect has been, that since the clinic opened, more than 50% of doses of methadone have been prescribed to be dispensed under supervision. Now that does not mean that those are the same patients all the time. We have started everybody on supervised dispensing, and of course, as they get stable, they do not need to go to the chemist everyday.

We have been careful in liasing with the pharmacies, which has been communicated to the patients, that non-collection of scripts are reported to us after 2-3 days, so that we can reconsider the tolerance issue. We take urine samples, to check that they are taking their methadone. We do not prescribe any tablets, any injectables, or any dihydrocodeine. We use all our products within their license, which means that we do not have a lot of people on benzodiazepines, for example. Now this may sound quite strict and draconian, and I think that like all protocols, it is there to be broken, sometimes.

We have kept our primary care focus with difficulty. We have tried to make ourselves a template for local GPs.

Results 1: Demographics 1997-2000

So what happened over these 4 years? What were the demographics of who died? There were 99 deaths in 1997, 32 in 1998, 34 in 1999 and 17 in 2000. A lot of other studies show similarly that nearly everyone was male (89%), the mean age was 30 (range 18-51), the majority were single (89%), and unemployed (85%), and were known drug users (91%), mostly heroin, with a long history of dependence (mean 7.6 years).

Looking at the treatment that people were receiving: only 38% were receiving any prescribed treatment at all, with only 20% on some kind of Methadone Maintenance Treatment. But when we looked at it, only 6% were getting the recommended guidelines-oriented oral mixture treatment. Which means that the rest of that 20% were probably getting something else, a mixture of tablets, injectables, and combinations of the two. The rest of the 18% on prescribed treatment, were almost certainly getting benzodiazepines and dihydrocodeine, prescribed by GPs wanting to help, but who were scared of prescribing methadone.

Results 2: Circumstances of Death:

The majority of deaths occurred in the deceased's own home (58%) without anyone present (81%). But in a significant minority (19%), somebody else was present. Witnesses often noted loud and distinctive snoring in the hours before death. That could indicate to us that something was going wrong, like respiratory depression or collapse. But in some cases, the witnesses thought that that was reassuring, because the person was obviously OK as they were snoring. Out of this 19% only one ambulance was called. And even in this case, it was called too late and the person died anyway. So there is a patient education message in there. Again, every year there was a significant minority of deaths in which diminished tolerance played a role. 10% of people died either when they had just come out of prison, or had recently left a detox programme and had started using again and died. These circumstances of death were stable over the four years. So none of these findings could explain the change in the number of deaths.

Results 3: Coroner's Findings: primary cause:

Heroin either on its own (49%) or in combination with other drugs was the primary cause of death in 72% of all cases. Methadone was considered to be the main cause of death in 11% cases on its own, and 10% of cases in combination with other substances.

Results 4: Trends in Opiate deaths:

So this was essentially more than 90% of deaths were opiate deaths. But we found that the profile of these were not the same over the 4 years. There were trends over the 4 years which differed.

Heroin deaths rose sharply, peaking in 1999. These deaths mirror the overall drug deaths in that time. Methadone deaths were completely different. They were stable and then they fell. Now this is in a period of time in which the number of patients on methadone in the city had more than doubled, but methadone deaths fell. Looking at this from a point of view of deaths per hundred treated patient years, which I believe has been done in Glasgow successfully, at its worst in Sheffield, that means that we were approaching 2 methadone deaths per hundred treated patient years. But that by the year 2000 we had gone to somewhere just above a quarter of a patient death per hundred treated patient years.

Why did heroin deaths rise?

So why did heroin deaths rise? We looked at the toxicology from post-mortems.

We found that in the years in which there was a higher mortality rate, people were dying from more than one drug (approx. 80%). The concomitant drugs that we found were alcohol and benzodiazepines. It is important to note that at this time in Sheffield, many GPs were prescribing benzodiazepines instead of methadone. Therefore, we can ascribe some of the rise in drug deaths to the rise in polydrug deaths. Many commentators have noted this, that polydrug deaths are rising because polydrug injecting is rising.

Involvement of Methadone:

Looking at the involvement of injectable methadone - it has played a large part in drug deaths than we would have expected given the number of doses that we think were being prescribed. This has fallen in 1999 and 2000 probably due to a change in the prescribing protocols. Nevertheless, it is unfair because most of the people, who one would prescribe injectable methadone to, are themselves the people most at risk of dying anyway. Diverted methadone was involved in 10 deaths, but falling. Methadone altogether, was only detected in 3 cases of deaths, in 2000 and was only considered to be responsible for 2 deaths in 2000. That is against a background in which the number of doses of methadone in Sheffield had rocketed.

Summary of Sheffield Deaths:

How Can GPs Help Reduce Drug Deaths:

I think we need a 3-pronged approach.

  1. Basic Harm Minimisation:
    1. We have to be aware of who is at risk of drug deaths.
    2. Advice re: injecting.
    3. Advice re: action in case of overdose.
    4. Advice re: dangers of methadone when take-home doses are given.
    5. Advice re: concomitant use of benzodiazepines and alcohol.
    6. Advice re: situations where tolerance may be lost.
    (NB. Also: testing and vaccination for blood-borne viruses and advice on avoidance of transmission).
  2. Providing safe evidence-based interventions:
    1. Methadone has been shown to reduce heroin deaths.
    2. This is mirrored in the Sheffield experience .
    3. Methadone maintenance target groups are the most likely to die if untreated: prioritising.
    4. Methadone can be prescribed and dispensed safely in spite of fears to the contrary.
    5. The National Guidelines are a good template for safe prescribing.
    6. Possible introduction of take-home naloxone for heroin users.
  3. Avoiding potentially harmful interventions:
    1. Benzodiazepines are a major contributor to drug deaths and are not a safe substitute for methadone. (Benzos cannot be dispensed on instalment prescriptions in England)
    2. Methadone should be prescribed within careful protocols (NB loss of tolerance situations, tablets, injectables, large take-home doses are risky).
    3. Doctors should take steps to minimise drug diversion.

Conclusions:

The vast majority of drug-related deaths in Sheffield and elsewhere are due to heroin. Methadone maintenance treatment reduces heroin deaths. It can be prescribed and dispensed safely. Yet only 6% of our cohort in Sheffield had access to methadone treatment within recommended guidelines.

So I think this raises a practical as well as an ethical question. Given that we have an effective treatment which is also safe, why in many areas is it so difficult to access this treatment?

5.4.1 Questions & comments for the Presentations

  1. I have prescribed reduced doses of benzodiazepine. Were any of the patients who died on reducing programmes of benzos? The other point is that you can prescribe benzodiazepines on a daily script.

Jenny Answer:

Sure it is possible if you are prepared to issue different scripts for every day with different dates on. Obviously with large numbers of patients that becomes difficult to manage. Also benzos can't be taken under supervision very easily, because they are tablets and they have to be taken more than once a day.

To the first question - I do not know if any of the patients who died and who were on benzodiazepines, were on reducing scripts of benzodiazepines. My own experience is that it is very difficult to implement a reducing script of benzodiazepines and that it is often hard to tell the difference between a slow reduction and something that is beginning to border into maintenance. Although nobody would want to say that under no circumstances should benzodiazepines ever be prescribed, they are not a first line harm minimisation intervention for a number of reasons at the moment.

  1. Methadone is a very powerful weapon. Good training, good operations to use them and good support are necessary. The message we have got to take out to LMCs, is not don't prescribe methadone, but use this powerful medication properly.
  2. A question to Jenny relating to the drug related deaths, is there any evidence of dual diagnosis, particularly psychiatric.

Jenny Answer:

Yes, we only looked in 2000. We actually found that about a quarter of the people who had died from drug related causes in this year had a genuine documented dual diagnosis type condition, which was often only ever brought to the attention of the coroner. It is something that we would like to look into in more detail.

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6. Workshops

6.1 Morning Sessions

1. Dr. Judy Bury: "Beginners' workshop - How to get started?"

  1. Substitute prescribing is not an emergency - there is a lot that GP can do while waiting for drug users to go on prescription.
  2. Importance of practice policy and local guidelines.
  3. Go into it and enjoy it!

2. Jean-Claude Barjolin: How to do it - shared care and other practical issues for primary care"

  1. This workshop explored the process of implementing shared care from a primary care perspective.
  2. It looked at the major practical issues and concerns that this raises in terms of the role of primary care in relation to other services and patients. It examines this development work in relation to the broader changes in primary care and the organisational impact this may have on the balance with other services and highlights the need for a strategic and joint working approach, management of local politics, along with well co-ordinated on the ground development work.
  3. The workshop highlights some of the concerns and choices that are facing primary care and other services in terms of implementing shared care. Some of the shared care and developmental models that are happening around the country were used to illustrate the above. The diverse involvement of primary care in relation to other services is significantly altering the landscape of drug service delivery and even to concept of treatment.

3. Dr. Berry Beaumont & Jim Barnard: "Shared care monitoring groups - what are they and how to set them up?"

  1. It is easy to get bogged down by responsibility and terminology - the monitoring group is to oversee the development of shared care arrangements.
  2. There needs to be more accountability from budget holders and communication with those on the ground who often are expected to do work unfunded.
  3. Monitoring groups, key to shared care - unlike DATs, joint commissioning groups have primary care membership.

4. Dr Sandy Wisley- Impact of drug use on a rural community and why GPs need support

  1. The presentation focussed on the multiple problems encountered in General Practice in a rural affluent setting faced with Heroin Abuse when 2.5% of the 10,000 practice population became affected in the period 1995-2000 and he unexpected lessons learned with experience.
  2. The practice staff were largely left to cope with minimal input from Substance Misuse Service Staff until the practice could no longer cope with the numbers attending and frequency necessary for appointment time commitment.
  3. Alternative treatment delivery for the needs of affected working fishermen posed considerable publicised differences of opinion with Health Board officials who advocated Consume on Premises Methadone Policy.
  4. The presentation focussed attention on the prescribing costs of Substitute Therapy out with allocated budget and also revealed the lack of funding for payment to the GP's unlike some Health Board areas in Scotland.
  5. The impact on individual health, family stress and impact caused to the community in general and financial wealth drain to the Illicit Drug Trade were clearly demonstrated.
  6. The mortality statistics showed clearly that attending patients had benefited from being in receipt of treatment in that the patients who had died were non-attenders and justified the workload and financial costs involved in treatment.
  7. The effects of drug misuse on the practice and staff were clearly demonstrated with the practice finding increased difficulty with GP recruitment with no applicants for a £70,000 per annum GP partner post.

5. Dr. Clare Gerada: "What is an intermediate practitioner (specialised generalist) and what do we need?"

  1. If primary care is to be in the front-line of treatment we need to be trained appropriately.
  2. The certificate in the management of drug dependency will create a tier of 'expertise in primary care to help support generalist GPs
  3. To do able to do this work we need on-going support and funding to provide this.

6. Sebastian Saville: "Drug users teaching other users and professionals to avoid overdose"

  1. Training to be provided and resourced for users and professionals on what to when confronted with an overdose situation.
  2. Serious consideration to be given to providing "user networks" and indeed individual users with naloxone.
  3. The obvious training of professionals and users on how to avoid overdose in the first place. Again, resourcing users to attend any form of training was considered important.

7. Kevin Williamson: Cannabis - should we support legalisation? Cannabis cafes for Scotland?"

  1. Gateway theory - 6 million users not viable - only 200 000 hard drug users.
  2. International situation - seven European countries taking steps towards decriminalisation - UK out of step.
  3. UK policy needs to be handed over to an independent body. Royal Commission?

8. Mary Hepburn: Managing pregnancy in drug users"

  1. Importance of appropriate service provision:
    Non-judgemental; Multi-disciplinary; Managing reproductive health as a continuum; Accessible (any route including self-referral). Acceptable (meeting both wishes and needs).
  2. Importance of individually appropriate care:
    Assess individual circumstances, medical and social. Different individuals may need different management for similar problems; Circumstances may change during pregnancy, so management plan needs ongoing revision.
  3. Importance of appropriate clinical care:
    Drug-using women have potentially high-risk pregnancies. Where possible evidence based prescribing (e.g. methadone in pregnancy). May have to accept lower grades evidence (e.g. effects of benzos, DF118, AN detox). Don't base prescribing on theoretical assessment of risks (e.g. AN detox); if no evidence of safety may also be no evidence of risk (e.g. don't ban AN detox from opiates/benzos, don't ban breast-feeding for drug users.) Management may often be compromise between risks and benefits.

9. Dr Lawrence Gruer: "Infected heroin - the chlostridium Novyi incident"

  1. The dangers of muscle infecting should be highlighted and the practice discouraged.
  2. A&E departments are a key interface with drug users, and how they are perceived by drug users is crucial.
  3. Drug users themselves should be involved in designing and selecting the test for information aimed at influencing their behaviour.

10. Dr David Young: Implementing supervised consumption - necessary for treatment or an abuse of human rights?"

  1. It was felt that supervised methadone was a necessity and did not represent an abuse of human rights. However it is probably more of an abuse to deny access to methadone treatment for those who need it, i.e. by waiting lists or non-availability of service provision.
  2. Most of the discussion focused on pharmacy provision. Like GPs, pharmacists need education and training to encourage them to partake in supervised dispensing. All pharmacists who provide supervised dispensing must do so in a way that respects the privacy and dignity of the client. Is funding adequate to allow this? Initially all this should be targeted at areas of greatest need. DATs please take note!
  3. Supervised dispensing should not become a permanent part of a client's contract but should adjust to individual need and circumstances.

6.2 Afternoon Sessions

1. SAS Scottish Action on Substances: Upholding the rights of drug users"

  1. Human rights of drug users are a neglected area.
  2. Support organisations such as SAS need to be set up across the country.
  3. There must be a balance between user rights and doctor/services rights.

2. Dr. Geoffrey Kewley & Pauline Latham: ADHD and substances - a missing link"

  1. Conditions such as ADHD and Bipolar Disorder in children and adolescents create a vulnerability to substance abuse by up to six times.
  2. Much pseudo-controversy, myth and misinformation has existed about ADHD, which has been confusing to clinicians and obscured the essential nature of ADHD as a biological condition of brain dysfunction, whose core symptoms are excessive inattentiveness and/or impulsiveness and/or hyperactivity. There are many possible complications of ADHD, including excessively oppositional and conduct disordered behaviour, anxiety, depression, obsessions, low self-esteem, learning difficulties, social skill problems and tics.
  3. ADHD is an eminently treatable condition and significant cases almost always benefit from the use of methylphenidate or similar psychostimulants. Up to 95% of people with ADHD can be effectively helped. Short-term side effects occur in less than 10% of those carefully managed, there being no evidence of long-term side effects with the use of methylphenidate for ADHD. Much confusion has existed in the substance abuse literature and in clinical practice about methylphenidate. It is classified as a sympathomimetic, not as an amphetamine, and indeed when used for ADHD does not behave as an amphetamine. It is in fact the condition of untreated ADHD and Bipolar Disorder which are addictive conditions, rather than the medications used to treat them.

4. Jane Allen & Adam Richardson: "Using GIS (Geographical Information System) to develop shared care"

  1. This workshop focused on how collecting and collating information using a Geographical information System (GIS) has enabled one shared care scheme to organise data storage, manipulation, analysis and presentation to develop a more complete understanding of it's working practice.
  2. In illustrating a practical application of this work it was possible to see how GIS could assist in planning treatment provision for drug users and begin to make interpretations about service delivery.
  3. The workshop rounded up with a case study which enabled the group to gain further understanding of the uses of GIS, and generally there was an acknowledgement of it's future potential.

4. Sophia Young: "Services for women - Turn around, women's section of Turning Point"

  1. Person centred planning essential for success in working with drug using women.
  2. Substitute prescribing availability vital to making changes.
  3. Service must work towards empowerment using a non-judgemental approach.

5. Dr. Chris Ford: "Using buprenorphine in primary care"

  1. Buprenorphine is a useful addition to the treatment of opiate dependency and can be well used in primary care.
  2. It is a useful alternative to methadone and can be used for detoxification and maintenance.
  3. It is important to develop guidelines for its use in primary care and this will be taken forward by a UK group resulting from the conference.

6. Dr. Sharon Russell: "The ABC of Methadone maintenance"

Our group was told that despite the title of this session I did not know all the answers to methadone Maintenance, if in fact there are any answers.

Training needed to:

  1. Have emphasis on "Safety" for the benefit of the drug user, the prescriber, and our communities.
  2. Have adequate and ongoing support.
  3. Be appropriate to the geographical area, it's problems and needs, to be relevant and credible.

7. Brain Whitehead: "Managing our own chaos"

Practitioners need to define their own primary boundaries before entering this work. Primary boundaries defined as:

  1. What is my role in this work? What can I do? What can I not do? What am I not prepared to do? What are my limitations?
  2. Practitioners require support and professional supervision. This is not simply desirable but essential. All practitioners should have professional support and supervision in place.
  3. Practitioners should only undertake a case load/ volume/quantity and complexity based upon their own competence and confidence.

8. Dr. G.R. Morse: "Supporting people towards abstinence"

  1. Abstinence must remain a choice in service provision and is part of the continuum of harm minimisation.
  2. Abstinence without preparation and support is worse than useless.
  3. Relapse is often part of recovery.

9. Don Lavoie: "National Treatment Agency- implications for primary care"

  1. The NTA is still in its infancy. It has a long way to go before it is clear how it will work and what impact it will have.
  2. The NTA is working for;
    a. Health gain
    b. Social gain
    c. Criminal Justice gains
  3. The NTA will promote standards and develop guidelines for DATs, PCTs HAs and service providers.

10. Dr. Linda Harris: Primary care working with the criminal justice system"

Important and controversial areas of debate and common agreement were:-

  1. Clear and consistent confidentiality and information sharing policy essential for professionals from the different agencies i.e. probation, police and health.
  2. The importance of a consistent approach within the teams and across the agencies regarding assessment, treatment planning and the application of sanctions and rewards in coercive treatment programmes
  3. The recognition of the importance of the strength of the partnership between health and criminal justice in invoking change in individuals with complex needs who offend to fund drug habits.
  4. The potential spin off of well trained magistrates and crown court judges becoming involved and receiving training leading to a showing of greater understanding of problem drug using and a genuine willingness to follow up clients.
  5. There was a lively debate focussed upon the impact of enforced drug treatment programmes on the doctor- patient relationship and whether or not this was a good or a bad thing. Attention was drawn to the fact that the research and evaluation applied to DTTOs up to press was limited and had made no attempt to measure the impact of coercive drug treatment methods on health and psycho social outcomes.
  6. There was also some discussion on the possible impact of the Human Rights Act on the delivery of enforced drug treatment programmes.

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7. Presentations - Day Two Afternoon

7.1 Introduction & Chair - Dr Muriel Simmonte

It is my pleasure to chair the final session of this conference. To briefly introduce myself, my name is Muriel Simmonte. I am a GP in Prestonpans, an ex-mining village in East Lothian, and have been caring for drug users in the practice for about 11 years. Like many others here I learned "on the job". Since 1992, I have also worked as a Primary Care Drugs Facilitator.

In this session we will be looking at the impact of government policy on drug services, primary care and on drug users themselves. For most of us here, the holistic harm reduction model of care for drug users is taken as a given. It was very heartening to hear Iain Gray this morning giving his support for harm reduction as the most effective strategy and to see this finally endorsed by the Effective Interventions Unit. It has also been shown that drug users retained in treatment are less likely to commit crime, and that keeping drug users out of prison is certainly beneficial to their health. But concerns have been raised that treatment programs could become methods of social control, and that the harm reduction model could be hijacked by a law and order agenda.

Purely in the interests of thorough preparation for this course, I spent last weekend in Amsterdam, and picked up a copy of an interesting magazine. It contains an article describing Holland's well known liberal and pragmatic response to drug use in contrast to that of other countries. I quote:

"The rest of the world continues its unending War on Drugs. Last year it was French President Jaques Chirac who blamed Holland for its drug troubles, even though, according to Time magazine, Holland has fewer addicts per thousand than France and Spain... One year ago, it was the U.S. drug Tsar Barry McCaffery who came to town to celebrate America's successful drug policy... He went even further, calling Holland's progressive policy, 'an unmitigated disaster', citing crime in Holland as proof, Huh? I don't know what he smokes, but this country is safe, and there is no place in the western world with more violence than America. But I guess when you're fighting a 'war' the truth sometimes has to be suppressed. Besides, Holland makes such a nice whipping boy. So in a bow to foreign pressure, the government has reduced the amount of soft drugs an individual can possess... maybe they should go further. If they recriminalize drugs, maybe they can wipe them out altogether, just like France and America. While we're at it, maybe France can give us some advice on how to end strikes and reduce unemployment, and the U.S can give us a few pointers about stopping violence in schools."

And a second quote from nearer to home, from our own Chris Ford at last year's conference:

"Previously, U.K. Drug Policy had a public health approach. Its aim was to help drug users to lead healthier lives and limit the damage caused by drugs, to themselves or others. It was very easy for primary care to understand its role. Since 1997 the policy agenda seems to have moved away from health improvement and harm reduction and become focused on the link between drugs and crime. Primary care appears to be less clear where it fits into this new agenda."

Our first speaker this afternoon, Martin Blakebrough, will address the impact of government drug policy on drug services and primary care. Martin is the director of Kaleidoscope, a church based project in Kingston, working with marginalized individuals, especially those with substance misuse problems. He has spoken at many conferences on harm reduction, and has also been invited to address the Scottish Executive. We look forward to his presentation.

7.2 What impact does government policy have on drug services and primary care? - Martin Blakebrough

My involvement in this conference started when Chris Ford said to me, "how do you get on with your GP?" And I looked rather blankly at her. The reason I was looking blank, was that I could not remember who my GP was. I was thinking that maybe he had spoken to Chris and wanted to make sure that he saw me more regularly. Luckily she does have the patience of a doctor, and stayed with me a little while, and explained about this conference here.

I can't fully understand why I have been asked to speak at this conference about this subject. Afterall I represent a relatively small project in South London and we are not a national body or organisation. It is a great honour to be here. Maybe the reason we have been asked to come here, is because we are very critical of government policy in relation to the Drugs Act of 1971 which saw a number of arrests in the last year or so. And particularly as a drugs agency, we are concerned about the arrests of people in Cambridge which came to be known as the Wintercomfort case - that people can be arrested for providing a shelter to the homeless seemed to me to be crude. Even if they had been incompetently running it, to actually end up in prison and have up to an eight-year sentence, seemed to me to be draconian. And of course this was doubled in terms of terror for GPs when the arrest of the Cumbrian GPs occurred which was also related to methadone.

So why have I been asked to speak. Has it to do with the 1971 Drugs Act. I think if Chris Ford had anything to do inviting me, anyone who knows her would recognise that she is a true non-conformist, and I guess that she was looking for a fellow non-conformist. So turned to a non-conformist preacher. So here you have it - a Baptist Minister who is better to preach at you than to give you any research documents.

Introduction:

The Labour Government has clearly placed the drug problem at the top of its social agenda. If any of you have seen the latest Pledge card from the Labour Party, point four of five is a crime pledge: 6000 extra recruits to raise police numbers to their highest ever levels, as we tackle drugs, and crime. Not police funding.

As we approach the election it is clear that substance misuse, and illegal drug use will dominate as an election issue from both political parties, vying for the political ground of being "tough on crime, and to be tough on the causes of crime" which they presume is drug use, although the evidence is sketchy. It is interesting to note that in their way of tackling drugs, there is no mention of GPs role or how drug agencies may play their role in tackling the issue of drug misuse. The question that you all have to ask yourself is, "have we a healthy drug policy?" It is my contention that we have a very mixed drug policy.

Topics of Discussion:

Here are some of the topics of discussion that I will be looking at today:

Firstly, the Americanisation of our policy.

I quote you some works written some years ago by works by Thomas Szasz, and he quotes some of the politicians of the era. He quotes Governor Nelson Rockerfeller, who declared to the Chamber of Commerce; "We the citizens are imprisoned by pushers. I want to put the pushers in prison so we can come out, ladies and gentlemen."

Then we also have the Republican, James Hanley, again in the 1970's. He calls the 60 000 known drug addicts in the USA only the visionary proportion of the iceberg, and expressed concern over the unknown present of potential addicts, asking how many vermin are infesting our high schools and colleges. Immediately what comes to my mind is the whole campaign that was recently launched, about "ratting on a rat". The whole concept in 1973 about drug users is repeated in the year 2000. Thomas Szasz summarises the USA policy on drug users in 1973, by saying:

"The past half century the American people have engaged in one of the most ruthless wars fought under the colours of drug and doctors, diseases and treatment that the world has ever seen. If a hundred years ago the American government had tried to regulate what substances its citizens could or could not ingest, the effort would have been ridiculed as absurd, and rejected as unconstitutional. If 50 years ago the American government had tried to regulate what crops farmers in foreign countries could or could not cultivate, the effort would have been criticised as meddling and rejected as Colonialism. Yet now the American government is deeply committed to imposing precisely such regulations. And on those of other countries by means of economic threats and incentives, and these regulations called drug controls or narcotic controls are hailed and supported by countless individuals and institutions both at home and abroad."

We see that whole war on drugs continually perpetuated by the USA. And we see it in the international context. We look at the horror that is upon the Columbian people. A government is kept in power even though its human rights record is one of the most appalling in the world, and is roundly criticised by Amnesty International. We have an ever-increasing population of people in America who are being incarcerated because of their drug use. We have a very high proportion of people from ethnic minorities who are suffering over and above that of their white counterparts. And sadly we have the murder of innocent individuals by those who say they are fighting for freedom and democracy. Innocent Columbians who may be graphically shown by the American anti-drugs plane killing a missionary and a baby. Imagine if that killing had taken place by a guerrilla force or freedom fighters. That would have been front-page news. The fact that it is a part of the war on drugs means that it only gets mentioned on page eight of a newspaper.

To turn to the UK - we have this mentality of following the leader, a hypnosis to follow whichever way the USA is going, regardless of the European community around us. Interesting to note, that a week after the murder of the missionary and her baby, we see British generals joining the war on drug producers in Columbia, reported in the "Guardian" on the 18th April. We see this not only in an international perspective, but also in our own drug policy in the UK - in the appointment of a Drug Tsar. We can't go as far as America, which has a General in charge, but we appoint a policeman to lead our fight on drugs, and we call it the Anti Drugs Coordination Unit. We have essentially a penal response to how we work with drug users.

We have now a record of neglecting human rights. I am appalled when I look at some of our clients who have been arrested, and they have been asked by the police to get someone to get them drugs. In another context, if someone asked me to burgle a house, and I burgled that house, that would be seen as entrapment. But it seems that justice is suspended when it involves drug users.

Finally, the international context is important because it reminds us of the racism within drug policy. When we look at which drugs are banned and not banned, it is clearly shown that it is primarily on racist grounds. The fact that alcohol and tobacco which fund American presidential campaigns are still legal drugs, and that drugs which are produced in the developing world like opium, cannabis and cocaine are illegal is clear demonstration of that. But further than that, we recognise that the prison population of those who are incarcerated for drugs, is disproportionate amongst the ethnic minorities of our population.

Criminalisation of Health:

So we can clearly see a criminalisation of health, which is dangerous and compulsory treatment as opposed to voluntary assistance. I have asked why they are forcing people into treatment, when there are not enough spaces for people who want to access it voluntarily. That was clearly shown in the example that we looked at in Plymouth before. How long is the waiting list for detox. It is often up to a year's wait in some parts of the country. That is where the debate is going wrong. We have also seen a huge investment in the Prison Service, to deal with drug users in prison.

Controversially, I have put the failure of Harm Reduction and Abstinence based models. I think that a lot of the debate about harm reduction has been successful. But sometimes where harm reduction does fail, as abstinence, is it becomes obsessed with the drugs themselves, and the whole drugs debate. In a way it stigmatises people themselves, and does not allow them to come out. In my opinion, the strength of harm reduction when it started, was that it saw drugs misuse as a community issue. When some of us went to India, we saw a whole new approach, which was focused on community development of disadvantaged people. We visited a rehab in India, for example, where some of the people in the rehab did not have a drug problem. It was a rehab because it was about enabling people to cope with the issues of disadvantage.

Social Inclusion:

I think the government have done some terrible things. About the stigmatisation of drug users, the language that has been used by government has been appalling. The attitude of Tony Blair when he says he is terrified for his children creates fear, and in such a climate you will not get fruitful discussion. But there are social liberals within government and also clearly within the Scottish parliament which is encouraging. Social liberals are actually seeing that the whole debate is much wider than the drugs issue.

You have to bring the debate in the social inclusion perspective. A classic example of this was put forward by the churches before the last election, and was called the "great banquet". This was a big meal where politicians, some business leaders and a proportion of disadvantaged people were invited. The idea was to get people together to discuss their life experiences. In my opinion that is what should be happening, we should move the debate from the singularity of drugs.

When looking at social inclusion we also need to be dynamic. We need to say that when we are running the projects, we need to have a broader perspective on life. That when are running projects for the disadvantaged, we also look at access to education, access to IT. Finally, we need to have the user voice more available to us.

The end to the ghetto:

So essentially, we have opportunity, but we need to end the ghetto situation of drug users. How do we do this? I think the central plank of government policy about housing living centres, is what we really need to concentrate on. We need to be a part of the movement where we provide care for drug users within a community setting, where it is seen that medication is just one solution for the problem that people face. For example, providing people in the healthy living centre with employment opportunities, recreational opportunities, of working with other problem groups in a voluntary capacity, of thinking about alternative therapies, in other words, of being imaginative.

At the heart of a healthy living centre, are GP's. They work in the middle of a community project, which means that when someone comes to see them for a certain problem, the solution is not merely to prescribe medication, but to look at the wider situation in which that person lives. How is that person coping with their children, for example? Are they able to gain access to a crèche? Is English her first language, does she have access to an English language course? And so on. I believe that GP's and church leaders are central to the community, with excellent possibilities of providing shared care, in a non-stigmatised way. There is another challenge for GP's - sometimes there are people who are living within such marginalized conditions, that they never make it to the clinic in the first place. We need to provide flexible, useable and healthy strategies to combat the problem of drug misuse. But we also need to ensure that we provide treatment that creates stability and looks at all elements of healthcare. One of the things that depresses me, is the pressure that there is for people to come off methadone.

What this Means:

Essentially, government policy comes with a health warning, which is that we cannot have a drug policy which is primarily located within the criminal justice debate. Having said that, it is also wrong to focus the debate within the public health sector. We have had that in previous years, in which it failed. What we need is a new way to look at the drug issue from within a community development and healthy living perspective.

We have an opportunity here, as we have been given resources which have not been available in the past, which enables us to provide a healthy living alternative. If we apply that then the health and well-being of the people will improve, and by default we will achieve the government's objectives. We need a community approach which will negate many of the problems associated with addiction.

Give Peace a Chance:

In conclusion - we need to look at Lady Runciman's report, and we need to advocate a proper and serious debate on the issues of drugs, which can only come if we have a Royal Commission.

We need to provide the appropriate treatment based on International research.

We need to move the debate away from a war on drugs to social inclusion of minorities.

A final plea, which is that health is not always about cure. It is also about helping people to live with the drugs that they have, and to provide them with an employment record, which allows someone to create a sense of identity for themselves. I close this address, with a quote from Lennon:

The war is over.
War has been lost.
What we have to do now is accept that
And give peace a chance."

Question:

1. I work on the Step project, which is a drug court. I don't think people are coerced into treatment. I think they make informed decisions about taking the option of marrying health and criminal justice. I think that it is up to us as clinicians to get it right, and get the messages of what works up on high.

Answer:

Perhaps the best way to talk about coercion, is to quote from the government's own Second National Plan. My view is that this is a negation of human rights, but perhaps it is not yours.

"There is clear evidence that drug misuse, particularly heroin and crack cocaine, is strongly associated with crime. Research indicates that getting drug misusers into treatment can considerably reduce both their illegal use of drugs and their offending behaviour. In one programme average drug expenditure fell from £400 per week to £70 with corresponding reductions in crime. That is why powers are being sought in the Criminal Justice and Court Service Bill to extend drug testing across the criminal justice system. These will include drug testing for heroin and crack cocaine, of arrestees charged with specified offences most commonly associated with the need to buy illegal drugs. The purpose of drug testing is to identify those offenders who misuse specified Class A drugs and support them into treatment where appropriate. A positive drug test would then be used formally in court bail decision."

Now someone here has allegedly, they have not been convicted, of a crime of burglary. They are then tested for drugs and their whole bail condition will be affected by the outcome of that test, even though they have not been convicted. To me that is disgraceful. That is forcing people into treatment, which is not acceptable, and a clear indication of the government's desire to coerce people into treatment.

7.3 What impact does government drug policy have on drug users? - Grant McNally

The second speaker this afternoon, Grant McNally, will look at the impact of government drug policy on drug users. Grant is a qualified social worker, current chair of the UK Assembly on Hepatitis C and head of the National Drug Users Development Agency.

I have been working in the field of social work, and in the drugs field since 1987, as a service manager, researcher, policy development trainer and lecturer. The Drug Users Development Agency, for which I am the national development worker, is funded through Comic Relief. We support and facilitate drug users self-organisations, self-organised drug user groups and we also support the professional involvement of drug users with drug services. Leading up to this general election, it might be interesting to look back at the last parliamentary term, because one of the things that is clear from it, is that many drug users, and drug professionals are very concerned with the trends in recent drug policy.

It is now thought that we are at a critical juncture, where harm reduction and all the successes that emanate from harm reduction policy may be sacrificed in pursuit of what can be seen as a dominant criminal justice agenda. This not only threatens the traditional model of intervention with drug users, but it also places health and human rights as a very low priority, and threatens to erode the harm reduction successes which led to low levels of HIV amongst the drug users. What we may see is an increase in HIV, Hepatitis C, Hepatitis B and possibly also increases in overdose deaths as a result of current policy.

The first part of this is new legislation such as drug testing and treatment orders, which compromises workers' ability to be honest brokers of harm reduction advise. It compromises it also between what I have heard termed, "alien relationships", between criminal justice agencies and drug services which are clearly focused towards monitoring and policing drug use within the parameters of the orders. This will clearly impact on any honest or empathic engagement around blood borne virus issues. For instance if drug user is on a DTO, how can they talk about safe injecting, about risk behaviour without disclosing that they are breaching the order. In addition to this, there are also existing legal policy barriers which have not been addressed, working against drug users health - for instance the laws relating to what is termed "injecting paraphernalia", which have clearly failed to keep up with new knowledge on blood borne virus transmission.

Although workers at the coalface of the services may have previously been expected to use intuition and address these innovatively, the Wintercomfort case clearly sets a caution for all professionals working with drug users. Scotland has taken a lead in this area through temporary amendment that the rest of the UK should be following, before we find the scenario of increased blood borne virus transmission. But rather than learn from Wintercomfort, and the problems of homeless drug users, what we find is a recent proposal to amend the legislation regarding knowledge of drug use on premises, to broaden the scope of this legislation and include cocaine and other drugs. This potentially can lead to more aggressive enforcement of the Wintercomfort type situations. This is driven by a Tory-controlled borough, Kensington Chelsea, and the proposal aims to increase powers to shut down crack houses.

There are other ways of doing this, but this could lead to greater exclusion of drug users from accessing hostels and housing. Further proposals to the Criminal Justice and Court Services Bill will also have an impact, as more users are detained in police cells, on remand and in prisons. There is great concern over the prevalence of Hepatitis C in the prison system, which is far higher than that found external to the prison world. All of these areas compromise workers, peer educators and act to push users away from services, rather than attract them in.

However there is some hope amidst this reactionary policy, through recent development - including constructive dialogue between central government and national drug users networks, and the growing links between the NTA, the Department of Health and the Methadone Alliance. Finally, something that I have been fighting for, which is movement on a National Hepatitis C strategy, which includes me. Now these developments are all welcome, but they will be diminished if action is not taken to put health back as the number one priority within drug policy. A new pragmatism is required, and to address this we really need to put harm reduction back in as the central plank of drug policy. We need to look intelligently at amending the Drug Misuse Act, to decriminalise possession and supply paraphernalia.

Questions:

1. As a GP working in Kensington-Chelsea, I am aware of how this policy is being driven towards the crack-cocaine legislation. My question is how you balance the needs of the community against those of the individual where intimidation and fear and the possession of shotguns if becoming more common. How do you protect the community if we retain the rights of the individual choosing not to go into treatment?

Answer - Grant: I agree there is a need to look at that situation, but if it is ill conceived, it will place homeless drug users in a position, which is detrimental to their health. It may also create situations which could lead to another Wintercomfort case, for example where needle exchange equipment is pulled out of hostels, and putting that community at risk. Examples of this have been where people have been stuffing their used needles into the mattresses, or in the pillows of the beds and the next person is then at risk from injection injuries. But I don't think that amending the legislation is the only method to crack down on the crack houses.

2. I know that both of you are very hostile to the Drug Testing Treatment Order. Can you not see a situation in which people have been convicted of offences, that it might be a reasonable thing to offer to a properly consenting and informed individual?

Answer - Grant: It is not so much a hostility to it, and I have worked in probation services, it is about do we have the courage to look at what is happening currently, and can we address the situation so that we can include harm reduction within that kind of work, instead of losing it all together.

Answer - Martin: Where my objection to it is, is the added element of abstinence orders. I think they are unrealistic. DTTO have sometimes been innovative, but where my objection comes in, is why do people who have committed an offence get access to superb treatment often, sometimes better than people who are voluntarily coming to treatment. If you come into treatment through DTTO, you will be fast-tracked into detox, yet I have people who are coming totally voluntarily, and will have to wait nine months. Why is this? (It is not in some ways against DTTO, unless they are unrealistic, for example in Grant McNally's example of people not being able to talk about their drug use.) But it should not be at the expense of people who are coming in voluntarily.

7.4 Summing up of the conference - Dr Tom Gilhooly

I would like to thank everyone who has been involved in the conference, especially Julia Cross and Lisa Liu. Thanks also to the Hilton staff who have done a good job in helping us to facilitate this conference. Also thank you to everyone at the Tall Ship for serving us last night. It has been great how this has developed over the past few years. Thanks to all the contributors.

The next conferences will be in:

I have thoroughly enjoyed this conference. It has been full of energy, seeing people and making contacts. There is tremendous warmth here. One of the things that we are going to have to do, is be brave, and stand up for what we know and believe in, and to be difficult.

To end with a George Bernard Shaw quote:

All progress depends on unreasonable man. Reasonable man adapts to the world about him. Unreasonable man forces the world to adapt to him; therefore all progress depends on unreasonable man."

We have to go out and be the unreasonable men and women who demand better care for their patients.

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8. Developments - Don Lavoie

A couple of years ago in this meeting, I made the statement that we have received some money to help develop the Substance Misuse Management and Primary Care Network. We have done that over the last two years, with the help of various people here today. Just to give you an update on that - good news, we have been successful in getting almost half a million pounds over the next three years, from the 'Invest to Save' Budget in the Treasury, because they have liked what they have seen of our work. So just to say that all of your efforts and your work has paid off, and for the next three years we will be developing more work in helping to promote primary care and substance issues.

Thank you very much.

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9. Conference Summary - Tom Gilhooly

The 6th National conference was the first to be held in a post devolution Scotland. The dual themes of Government Policy and Training gave a new impetus to the Scottish Executive approach to drugs. The keynote speech by Mr Iain Gray, Deputy Justice Minister in the Scottish Parliament who has responsibility drugs policy, gave the clearest indication yet from a senior politician that harm reduction is to be the mainstay of future drugs policy. The conference itself took on a political dimension by provoking pre-conference meetings with the Scottish Executive and members of the Shared Care Network for Scotland. It was important that the minister had something concrete to say on training to a national conference which had this as one of the main themes! The results of these meetings was a commitment from the Scottish Executive to include primary care in the developments of the training agenda and further meetings are planned to take this forward.

The conference was one of the most diverse and stimulating yet. A wide range of subjects were covered in the workshops and the response from delegates was extremely positive. After the traumas of Shipman and Carlisle, it was a welcome break and a chance to recharge the batteries for the task ahead. My personal feeling after the conference was one of great optimism and renewed resolve. The conference is gaining not only in numbers but also in its own importance in shaping the future of the services we can provide to drug users. Primary Care is and will be at the very centre of such efforts and we can all play a vital role in its development.

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10. Editor's Remarks

Each year the conferences have become bigger and have developed a wider audience. Although primarily started for GPs we acknowledge this wider audience and it will be reflected in next year's conference. The plan is to move to 2 full days and have more core involvement of other disciplines working in primary care.

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11. Appendices

11.1 Bibliographies

Jane Allen
Jane Allen has a background in nursing and has worked in addiction services since 1994. She is currently the shared care co-ordinator for the Substance Misuse Management Project (SMP), which is the shared care scheme within the two London boroughs of Brent and Harrow.

Jean-Claude Barjolin
Jean-Claude Barjolin is currently the co-ordinator for the primary care network Substance Misuse Management in General Practice (SMMGP). This involves the development of the SMMGP newsletter and web-site, smmgp.demon.co.uk, and the expansion of newsletter distribution and network activities. The other aspect of the post is as Primary Care Development Advisor. This role supports primary care, other providers and planners in the development of local models of shared care or approaches for the management of drug users in primary care.

Jean-Claude Barjolin was previously the co-ordinator for the Substance Misuse Management Project (SMP) at Brent and Harrow Health Authority. This included the development and management of a formalised model of shared care and GP facilitation. This experience included the restructuring of specialist services to support primary care. Jean-Claude has been an organiser of Managing Drug Users in General Practice since the first conference in 1996.

Jim Barnard
Jim Barnard has been working in the field of substance misuse for ten years. During this time he has worked in both the voluntary and statutory sectors as well as working in Research and Development for two years (Southampton university). He presently works for SMMGP based at the Substance Misuse Advisory Service (SMAS) giving service development advice to stakeholders in the drug treatment field throughout the country. He has worked on primary care development in local, regional and now national roles as well as in a research capacity.

Publications
(1998) Shared Care on the Isle of Wight: Journal of Substance Misuse.
(1999) Caring and Sharing: modelling successful shared care. Druglink.
(2000) A Share of the Action: GP involvement in Drug Misuse Treatment in Greater Manchester. Drugs: Education, Prevention and Policy.

Dr Berry Beaumont MRCGP FFPHM
Dr Berry Beaumont has been a GP in London for the last 15 years, working with drug users in the practice for 12 years, GP substance misuse lead for Camden and Islington Health Authority and Chair of Shared Care Monitoring Group. Dr Beaumont is a member of the Royal College of General Practitioners' Export Advisory Group for new Certificate and Diploma courses. She is the Editor of the book 'Care of drug users in general practice - a harm minimisation approach' published by Radcliffe Medical Press August 1997'.

Martin Blakebrough
Martin Blakebrough was educated at a Catholic Boys secondary school, which was strange given that his father was a Baptist minister. His father was also the founder of the Kaleidoscope Project where Martin was brought up. On leaving school, Martin went on to complete a degree in Theological Studies at Thames Polytechnic and became a neighbourhood worker in Canning Town, East London.

In 1987, Martin went on to train for the Baptist Ministry at South Wales Baptist College, and obtained postgraduate qualifications at Cardiff University. His first pastorate was from 1989 - 1993 in Rossendale, Lancashire. In that time, he established a community centre, wrote a regular column in the local paper and advised the local council on drug policy.

In 1993 Martin was approached by John Bunyan Baptist Church to become their Minister. During that time Martin also took on work at Kaleidoscope, leading him to become responsible for overseas development and then Deputy Director and finally Director of the Project. At present he is undertaking a Masters degree in Community Care Management.

Kaleidoscope is a church based project based in Kingston that provides holistic care to people on the margins of the community. It has a specialism in the area of care for those with substance misuse problems, and has pioneered needle syringe exchange, a computerised methadone-dispensing programme, and championed the cause of rehabilitation before detoxification. It has recently been given a grant to develop a state of the art ICT centre, and is internationally regarded for its training programmes.

Martin was appointed to the ACMD in 1999, is on the executive of FORUM, which is a network of agencies in South East Asia, and a regional Minister for the Thames Valley area.

Martin has spoken at a number of conferences including the International Harm Reduction Conferences in Paris, Geneva, Hobart and Delhi. He has spoken at a number of venues from small churches to the European Assembly. He is particularly proud to have been invited to address the Scottish Executive and has written for a variety of religious and secular publications. Martin has also taken part in Panorama, The Mark Thomas Product and Heaven & Earth. He has a number of interests, football, travelling and alt.country and enjoys family life with his partner Debby and two sons Luke and Reuben.

Dr Judy Bury
Dr Judy Bury is Primary Care Facilitator (HIV/Drugs) for Lothian Health. She leads a team that offers support to GPs and other members of the primary care team in caring for drug users and caring for people with HIV infection. Dr Bury used to work in general practice and then in the Community Drug Problem Service in Lothian. She is one of the authors of "Managing Drug Users in General Practice", a handbook produced for GPs in Lothian. She was involved in setting up a scheme for supporting GP practices caring for drug users and for supervising methadone consumption in Edinburgh.

Dr Chris Ford MRCGP
Dr Chris Ford Has been a GP in London for 15 years and works with a large number of drug users in general practice and enjoy this work. She also works as the Clinical Director of the Brent Specialist Drug and Alcohol Agency, which is clinically lead by primary care and managed by the voluntary sector. She is the chair of the RCGP HIV Working Party, which is soon going to become the RCGP Sex, Drugs and HIV Task Group and is one of the founders of this conference and the SMMGP newsletter. She is also the chair of the Methadone Alliance, a drug user led organisation, which encourages drug users and professionals to work together to try and improve drug services.

Dr Tom C Gilhooly
A General Practitioner in Parkhead in Glasgow's east end for the past twelve years, he became involved in managing drug users ten years ago. He was chairman and founder member of the Methadone User Group (MUGS) from which the current GP clinic scheme in Glasgow grew. Has been Visiting Medical Officer at the Glasgow Drug Crisis Centre for the past seven years and has been a member of the Scottish Advisory Committee on Drug Misuse for five years. He is also chair of the Scottish Shared Care Network and is a founder member of Scottish Action on Substances (SAS). He recently left his post as Clinical Director of the Lanarkshire Drug Service to take up the position of Clinical Co-ordinator for Glasgow Shared Care.

Dr Linda Harris
Dr Linda Harris is a GP currently working half time in an urban (PMS Pilot) training practice in Wakefield. For the past 4 years she has also worked half time as the Clinical Lead for the Wakefield and District Primary Care Substance Misuse Service. The service is primary care led and delivered in partnership with the voluntary drugs agency Turning Point as part of a Local Development Scheme. This locality based generalist specialist service incorporates the Beacon Award winning STEP Project. The STEP (Substance misuse Treatment and Enforcement Programme) is a multi agency partnership bringing health and criminal justice agencies together in the war against drugs and crime. It has piloted the UK's first drug court and achieved national recognition as a comparative site in the Government's evaluation of the new Drug Treatment and Testing Orders.

Dr Harris has been involved with the STEP project since its inception over two years ago and is a member of the Criminal Justice Advisory Group that manages the project. She is an inaugural member of the International Association of Drug Court Professionals and has visited a number of American drug courts.

Last year Dr Harris became a research assistant with the Centre for Research in Primary Care, University of Leeds and is currently undertaking research into enforced drug treatment programmes. She is an Executive Committee board member of the Wakefield West Primary Care Trust with a lead role in the local implementation of the NSF for Mental Health.

Dr Mary Hepburn BSc, MD, MRCGP, FRCOG
Dr Mary Hepburn is a Senior Lecturer in Women's Reproductive Health, Glasgow University Department of Obstetrics/Gynaecology and Social Policy Social Work and Consultant Obstetrician & Gynaecologist, Women's Reproductive Health Service, Glasgow Royal Maternity Hospital.

Dr Hepburn trained as a general practitioner and then as an Obstetrician/Gynaecologist. She established and is Consultant in charge of the Glasgow women's Reproductive Health Service, a city wide, community based, multidisciplinary service for women with social problems including drug use. She is Senior Lecturer in Women's Reproductive Health at Glasgow University, jointly in departments of Obstetrics/gynaecology and social Policy/Social Work.

Dr Jenny Keen
Until March 1998 Dr Jenny Keen was a GP Principal in Sheffield, working at a practice with a special interest in the treatment of drug misusers. Since than she has been one of two doctors employed by Community Health Sheffield to develop and implement a new primary care service in Sheffield for the treatment of drug dependence. This is based on a 'deputising' model which allows GPs to retain drug misusers for General Medical Services whilst undertaking varying levels of involvement with their drug-related problems. The new service aims to develop shared care in the city whilst stimulating the involvement and training of primary health care teams in the treatment of drug misuse. Dr Keen has been funded by NHS Trent Research and Development to carry out a large-scale controlled trial to measure the outcomes of the new service and she is undertaking this work at the Institute of General Practice and Primary Care at the University of Sheffield. She is also involved in the medical supervision of heroin users undergoing residential detoxification and rehabilitation at Phoenix House, Sheffield.

Publication:
Keen J, Rowse G, Mathers N, Campbell M, Seivewright N (1999). Can methadone maintenance for heroin-dependent patients retained in general practice treatment reduce criminal conviction rates? A pilot study. (Submitted for publication March 1999).

Dr Geoff Kewley MB BS FRCP FRCPCH FRACP DCH
Dr Geoff Kewley is a Consultant Paediatrician specialising in the management of children with neurodevelopmental difficulties, especially Attention-Deficit/Hyperactivity Disorder and related problems. In 1993 he established the Learning Assessment Centre in Horsham, West Sussex, from concern at the lack of availability of effective services for such problems, having worked for the local NHS Trust following his relocation to Britain from Australia in 1990. He had been in practice in Australia for 16 years as a General Paediatrician with a special interest in ADHD. Dr Kewley therefore has considerable experience in managing children and adolescents with ADHD and related difficulties in both Australia and Britain.

The Centre is an independent NHS provider, also able to see patients privately, providing a comprehensive and experienced multiprofessional assessment and management service. It receives referrals from all over the UK and abroad.

Dr Kewley authored a landmark book on ADHD in the UK in 1999 entitled 'ADHD: Recognition, Reality & Resolution'. It is published by David Fulton Publishers and is available from them or from the Learning Assessment Centre. This book provides a welcome source of factual information for a wide variety of professionals and parents and is especially relevant to the management of ADHD in the UK. It also, however, provides a broad base of relevant information appropriate for those overseas. The book has also been translated into Japanese and is available in Australia.

Dr Kewley lectures on ADHD nationally and internationally, has written several book chapters and articles on the subject, and is particularly interested in encouraging professional awareness of the facts and reality of ADHD as part of the appropriate development of services for children's mental health.

>Mrs Pauline Latham
Pauline Latham has been instrumental in the establishment and development of the Learning Assessment Centre, where she has been Centre Manager since its inception in 1993.

Previous roles have included Personal Assistant posts in the medical field as well as a period in a key position in a preparatory school, which has brought her into regular contact with professionals, parents and children. This, and her personal experience of ADHD as a parent, has given her a valuable understanding and insight into the different needs of children and their families, especially sufferers of ADHD, as well as the difficulties facing those involved with them.

Mrs Latham has written several chapters and articles on ADHD for books and professional journals and talks to both professional and non-professional audiences, at conferences, seminars, in-service training days etc.

Don Lavoie
Don Lavoie is the Associate Director of the Health Advisory Service and leads the Substance Misuse Advisory Service (SMAS), a service dedicated to assisting commissioners around the country improve their drug and alcohol treatment services.

SMAS manages the Substance Misuse Management in General Practice project which provided direct support to GPs, Primary Care Teams, PCGs, PCTs, Health Authorities, Health Trusts and Drug Action Teams on the establishment and development of Shared Care schemes. The project is also responsible for the quarterly newsletter and the web site offering support and a forum for GPs working with drug users.

Don is also the Chairman of one of the working groups supporting the establishment of the National Treatment Agency and is actively involved in setting the direction of the emerging agency.

Prior to taking up this post with SMAS, Don was the Commissioner for Substance Misuse at the Lambeth, Southwark and Lewisham Health Authority.

In the early 90s, Don was the Regional Alcohol Co-ordinator at North West Thames Regional Health Authority. He has also held posts in the voluntary sector working for both Accept and Turning Point.

Trained as a Psychologist in the USA, he worked as the Director of Alcohol Services for Solano County Mental Health, one of the nine counties in the San Francisco Bay area of California. He moved to the UK in 1986 and has worked in the addictions field since his arrival.

Dr Gordon R Morse
He is a single handed GP principal in rural Wiltshire, a GP Trainer, and Honorary Lecturer in General Practice at Southampton University Medical School. He has also been Medical Adviser to Clouds House, one of the UK's longest established residential treatment centres for chemical dependency. At Clouds he has been responsible for the detoxification and medical care of nearly 2000 chemically addicted patients over recent years. He has designed and chaired various conferences including "Innovations and Insights in Drug Abuse" at the Maudsley Hospital last year. He is author of "Detoxification" (Quay Books) and will be publishing a small reference work for GPs training in addiction, later this year. He is currently serving on the Wiltshire Shared Care Monitoring Group and has been charged with rolling out Generalist addiction training throughout Wiltshire.

Adam Richardson
Adam Richardson is a student studying geography at the University of Hertfordshire. He is currently on a twelve-month placement as part of his degree working as a GIS (Geographical Information System) Assistant for SMP

Dr Sharon Russell
Dr Russell has been a full time GP in Lanarkshire for 8 years and worked on a sessional basis for Glasgow and now for Lanarkshire Drug Problem Service's. Other interests include Medical Ethics and Law, and Associate Advisor for CPD and Clinical Governance.

Sebastian Saville
Sebastian Saville is the Development Strategist of the Stapleford Trust, Medicine and Technology in the Management of Addiction and Addiction-Related Crime, London.

Dr Richard Watson
Current Posts, Principal and Trainer in General Practice, Craigallian Medical Centre, 11 Craigallian Avenue, Cambuslang, Glasgow G72 8RW

Richard has also worked promoting methadone maintenance in primary care for many years and has organised many training seminars for GPs in the Greater Glasgow General Practitioner Drug Misuse Clinic Scheme. He has spoken at two previous RCGP conferences and at many other meetings.

He has written several publications on the topic of methadone maintenance in primary care and has been involved in discussions about training for GPs caring for drug users in Scotland.

Publications:
Wilson P, Watson R Ralston G. Methadone Maintenance in general Practice; Patients, Workload and outcomes. BMJ 1994; 309-641-644 (10 September)
Wilson P, Watson R, Ralston G. Supporting Problem Drug users: Improving methadone maintenance in general practice. British Journal of General Practice. September 1995; 398: 454-455.
Watson R. Method in Methadone. The Herald 19.10.94
Watson R. Working with drug abusers. Medeconomics. November 1995.
Watson R. Practice questioned - Methadone for Drug Abusers. Update 126-131. 4 September 1996.

Brian Whitehead
BSc Dip Ed. Dip. Couns.
Counsellor/Behaviour Therapist in General Practice. He trains extensively on motivation interviewing and is one of the co-founders of the conference and the SMMGP newsletter.

Dr David Young
Qualified Guy's Hospital; 1974. Medical Officer in Psychiatry, Paramatta Hospital, Sydney 1997-98 where I first worked with clients with substance misuse problems.

Principal in General Practice, Macclesfield, Cheshire 1979-2001.

In 1983-85 David chaired the local Drug Advisory Committee which was responsible for establishing a community drug team in Macclesfield. He has worked with, and prescribed for, substance misusers in general practice since 1983. In 1997 he was funded to establish a prescribing clinic for stable clients in East Cheshire at his practice; this was irrespective of whether the clients were or were not registered patients at the practice. In January 1999 David was asked to take over as lead Clinician for the East Cheshire CDT following the retirement of the Consultant Psychiatrist who previously had that role. In April 2001 he retired from General practice to become full time lead Clinician for East Cheshire C.D.T. In April 2002 his service will be directly managed by the East Cheshire P.C.T.

In 1997 he tried to persuade his Health Authority of the need to have supervised dispensing of methadone as a treatment option to reduce methadone 'leakage', but it was only after the Clinical Guidelines were published in 1999 that this has become available as a treatment option in some parts of East Cheshire.

11.2 2000 Consensus Statement - "Are We Drowning or Riding the Waves? The Treatment of Drug Users in Primary Care"

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 be extended and the proposal more widely circulated.

Previous consensus statements can be found on the SMMGP website.