One of the things I am most proud of in the 27 years I have been a GP is the way many working in Primary Care responded to the challenges posed by treating substance misuse and dependency, with the resultant growth too in Shared Care services. In Birmingham - where I am based - the number of practices providing OST rose from 8% to over 65% in a decade. I now fear that all this progress is under threat from multiple directions and if lost, all that experience and enthusiasm will be very difficult to replace.
The years of austerity have been hard for many but the move of public health into Local Authorities has opened up drug and alcohol treatment services to far more financial constraints than had they remained inside health budgets. Retendering and enforced cuts in existing contracts have left providers with no option but to make significant changes. Some have been forced to merge and despite what is supposed to be a culture of “localism providing tailored local solutions”, the number of options dwindles. It is hard to see services being awarded to small local third sector organisations in this climate.
Where providers have to make cut-backs, then it is so that the cost of providing services from multiple primary care settings, funding workers for this service plus paying GPs can seem expensive compared to operating out of one or two hubs with central prescribers and workers. Payment by results targets based on numbers completing and being discharged from OST can also work against Shared Care with a perception that less people complete treatment in Primary Care.
Given this, why am I so passionate that Shared Care should continue? Most of the people I see who are on OST are incredibly complex, not so much from the point of their drug use but as an ageing cohort with an array of physical and mental health problems. Many of these such as COPD, coronary heart disease, hepatitis C, renal failure, depression, anxiety and PTSD are chronic conditions that need long term support and management in a Primary Care setting. Engagement with treatment for these conditions can be erratic and by silo-ing off the OST into a specialist service I worry that our ability to treat these people will be severely compromised.
If our aim genuinely is to provide holistic care and improve the lives of those affected by substance use then we need to commission services that deliver health, OST and recovery to work as a single package. Until then having an option for Shared Care treatment built in to local provision does at least afford that opportunity for some.
It would be a sad day indeed for me if at the end of my career in general practice, Shared Care for people who use drugs had dwindled back to the minority interest it was when I first started out.
Dr Steve Brinksman
SMMGP Clinical Director
This article was first published in DDN Magazine, June 2018 edition.