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ROYAL COLLEGE OF GENERAL PRACTITIONERS
CONFERENCE REPORT
3rd National Conference
MANAGING DRUG USERS IN GENERAL PRACTICE
‘New NHS - Same Dilemmas: Caring for Drug Users
in the New NHS’
24 April 1998
Murrayfield Stadium Conference Centre, Edinburgh
HIV/AIDS Working Party of the RCGP
Conference supported by :
Educational grants from Brent and Harrow Health Authority, Camden and Islington Health Authority
(HIV, Drugs & Alcohol Services), Lothian Health, East London and City Drugs Services
Commercial sponsorship from Carfax Publishing, Boehringer Mannheim, Du Pont Pharmaceuticals Ltd,
Lipha (Merk), Turning Point
Conference Report
J-C Barjolin & Dr Chris Ford
June 1998
3rd National Conference
MANAGING DRUG USERS IN GENERAL PRACTICE
New NHS - Same Dilemmas:
Caring for Drug Users in the New NHS
Supported by the HIV/AIDS Working Party of the RCGP Conference Organising Committee
Jean-Claude Barjolin
Dr Berry Beaumont
Dr Judy Bury
Dr Chris Ford
Dr Claire Gerada
Brian Whitehead
Conference Organisers - RCGP Courses London
Jennifer Goulding
Lisa Liu
Conference Organisers - Primary Care Facilitator Team, Edinburgh
Caroline Jaquet
Report Editors
Jean-Claude Barjolin
Dr Chris Ford
Rapporteur
Jean-Claude Barjolin
Educational Grants
Brent & Harrow Health Authority
Camden & Islington Health Authority HIV, Drugs & Alcohol Services
Lothian Health
East London and City Drugs Services (Tower Hamlets Healthcare NHS Trust)
Commercial Sponsors
Carfax Publishing
Boehringer Mannheim
Du Pont Pharmaceuticals Ltd
Lipha (Merk)
Turning Point
Reckett & Coleman
For comments or further information (including SMMGP Newsletter) please contact Dr Chris Ford at
the Substance Misuse Management Project, Brent and Harrow Health Authority, The Harrovian
Business Village, Bessborough Road, Harrow HA1 3EX. Tel: 0181 9661109

REPORT CONTENTS
1. FOREWORD Dr Chris Ford
2. INTRODUCTION AND BACKGROUND TO THE CONFERENCE p.2
3. SUMMARY - KEY POINTS FROM 1998
4. CONSENSUS STATEMENT 1998
5. PRESENTATIONS
Chair’s Introduction to the Morning Session - Dr Claire Gerada Welcoming Address - Mrs Nicola Munro, Chair of the Scottish Advisory Committee on Drug Misuse (SACDM) Political Changes in Primary Care in England, Wales & Scotland and How They Affect the Care of Drug Users - Dr Susanna Lawrence Progress Towards a National Network of GP Support - Dr Berry Morning Session Discussion - Shifting Resources for an Integrated Chair’s Introduction to the Afternoon Session - Dr Judy Bury What Research is There and is it Useful to Primary Care? 6. WORKSHOPS
1. Shifting care or shifting costs. Setting up a shared care scheme -Jean-Claude Barjolin 2. Training verses competence - Dr Susanna Lawrence 3. Regional Drug Misuse Database and other alternatives to the Addicts Index - p.19Peter Knight and Arun Sondhi 4. Specialist services - statutory or voluntary? The role of the voluntary sector. p.19Why you need us - Sebastian Saville 5. Secondary care & shifting resources - Paul Carvajal 6. Widening the team. Working with pharmacists - Jane Pettifer 7. Giving drug users a voice. Setting up a local drug users self help organisation - Scottish Drug Action Group 8. Working outside the inner cities - Andy Rome 1. Community detoxification and the use of lofexidine - Dr Richard Solomons 2. Pros and cons of heroin prescribing - Dr Roger Smith 5. Working with the homeless drug users - Dr Nat Wright 6. GPs are not enough. Supporting the PHCT - Caroline Jaquet 7. Getting going on research - Nicky Metrebian 8. When to suggest residential rehabilitation - Dr Gordon Morse 7. DEVELOPMENTS
Care of Drug Users In General Practice - A Harm Minimisation Approach North West London Combined GP Support Scheme 8. EDITORS REMARKS - GOING FORWARD
The Development of Primary Care and Specialist Services 9. REFERENCES
The management of drug users in General Practice has seen a number of significant changes over the past 3-5years.
This has included the setting up of increasing number of GP shared care schemes, a shift towards primary carebeing more in the driving seat of service provision and the vast increase in the prescribing of methadone byGeneral Practitioners. There is a move on a Government and national level to rationalise drug treatment afterthe generally good but extreme incongruities of “the British System’.
Immediately following the 1998 conference, the Government 10 year strategy for drugs was launched ‘Tackling
Drugs Together. Building a Better Britain’ (1) which reinforced this and stated unequivocally that “There is
growing evidence that treatment works.(p.22)” and one of the key objectives is to “Increase participation of
problem drug misusers, including prisoners, in drug treatment programmes which have a positive impact on
health and crime. (p.22)
This annual conference is playing a part in that change, bringing together GPs and other health professionalsfrom across the UK to develop a shared understanding of the key issues currently facing the field andestablishing a network for exploring and developing these.
The conference is an annual event under the umbrella the HIV/AIDS Working Party of the RCGP and we hopethis momentum will take us into and well past the millennium.
Dr Chris Ford
INTRODUCTION AND BACKGROUND TO THE CONFERENCE Edinburgh was this year host to the third national RCGP conference ‘Managing Drug Users in General Practice.
New NHS - Same Dilemmas: Caring for Drug Users in the New NHS’. It seemed fitting that the conferencemoved out of London in order to reflect the national diversity of the work being undertaken. The focus hadreturned to Scotland, the source of much pioneering and dedicated work in substance misuse. The conferencewas full to capacity with over 130 delegates, the largest gathering to date. The venue located in MurrayfieldStadium seemed appropriate in terms of the growing momentum of this annual event.
The conference was first held in 1996 as a GP initiative as it was felt that the few GPs or schemes doing thework were experiencing common concerns, yet working largely in isolation.
The first conference looked at the ‘why and how’ of managing drug users in general practice. In fact itaddressed the question ‘if’ general practice should be managing drug users at all. 1997 focused on ‘embracingthe diversity’ of managing drug users in general practice; diversity in terms of the variety of roles andapproaches within general practice and in terms of multi agency working and shared care. 1998 had a focus ona national structure of support, in order for primary care to influence this field of work within the new proposedand evolving primary care led NHS. The challenge might be how to maintain a focus around the managementof drug users in general practice within the interesting if somewhat blurred vision of the future of primary care.
To bring together GPs and other health professionals working with drug users in general practice to examine,explore and debate current practice and concerns. The focus has deliberately been primary care as there haspreviously been little significant opportunity for primary care centred discussion.
Developing the conference ‘initiative’: • The conference committee initially came together in 1995 as a subgroup of the HIV/AIDS Working Group • The SMMGP Newsletter (Substance Misuse Management in General Practice) was developed for the 1996 • The proposal for a national GP Network was developed as an outcome of the 1997 conference;• The new Department of Health Clinical Guidelines have had three members of the conference committee Organisation and support Has been given by members of the Conference Committee, the Courses Unit of the RCGP, and the SubstanceMisuse Management Project at Brent and Harrow Health Authority. The 1998 conference was also supportedby the Edinburgh Primary Care Facilitation Team • 4th National Conference to be run on Friday April 23 1999. Venue to be decided.
• The national GP Network is currently looking to secure funding. Updates will be circulated in the SMMGP
• SMMGP newsletter will continue to be disseminated four times a year. For information see below:
For further information on the SMMGP Newsletter or for comments on the report please contact Dr
Chris Ford at the Substance Misuse Management Project, Brent and Harrow Health Authority, The
Harrovian Business Village, Bessborough Road, Harrow HA1 3EX. Tel: 0181 9661109

3. SUMMARY - KEY POINTS FROM 1998• There is an increasing and changing strategic response to drug use together with a valued and pragmatic contribution by GPs through substitute prescribing.
• All GPs are probably seeing drug users, if not declared. Few other areas of general practice are so challenging yet so valuable to the community.

• The new NHS White Paper (2) has good and bad news for drug users. There is a shift in national thinking
about managing drug users. As changes are implemented, general practice will have to be careful tomaintain the focus and innovation around substance misuse if it is to ensure accessible and appropriateservices within primary care.
• There is a growing opportunity and need for General Practice to be at the centre of political, strategic and operational developments in this field.
• There is progress towards a national network for supporting primary care in managing drug use. Its aims, also consistent with a more influential role for General Practice, being to establish a stronger nationalprofile and support structure, both operationally and politically for GPs undertaking the work of caring fordrug users.
• There is increasing recognition of the need for user involvement. There is a need to remember drug user rights and not merely perceive a ‘drug user’, but a regular patient or member of the community withlegitimate health or personal concerns. User involvement can have enormous value in informing GPs,service management, commissioning and planning groups in the design and response of services.
• There is a frequent reluctance by practitioners to look at alternatives to methadone maintenance. Why deal with something as complex as opiate addiction through the use of one drug and one approach.
• The value of maintenance and methadone is supported, but it is advocated that GPs need to be on the leading edge of trying different approaches and targeting care for different patients or at different treatmentstages.
• Substitute prescribing is only the first step in recovery and treating underlying problems is still almost • There is very little research available to support this area of work in primary care. Systematic reviews of all data on community based treatments, improved information and monitoring systems, and imaginative highquality primary research are much needed.
• The focus is no longer on whether or not general practice should be doing the work, but on a positive commitment to ‘doing it better’.
As in the 1996 and 1997 conferences, delegates agreed a number of clear and strong consensus statementswhich arose from the discussion and pooling of experience on the day. Dr Judy Bury who chaired the afternoonsession and closed the day urged that these be quoted, heard and used in higher circles.
As general practitioners and members of the Primary Health Care Team we continue to be
committed to caring for drug users.

We are preparing to meet the challenge of adapting to new models of working in the ‘New NHS’ -
given appropriate support and resources.

We believe that the management of problem drug use in primary care should be included as an
indicator in the Health Improvement Programme (HIP). (3)

Collaboration with a range of services including specialist drug services, the voluntary sector and
pharmacists remains essential to the provision of good care.

We support the proposal to establish a new primary care network to improve the provision and
effectiveness of care for drug users in the general practice setting.

1997 Consensus Statement
Managing Drug Users in General Practice ‘Embracing the Diversity’

It is clear that many GPs are involved to a high standard with the care of drug users throughout the UK.

• There is a lack of and a need for primary care-based research on effective interventions and models of care.
• Although there has been an increase in support provided by specialist services, there is an urgent need to provide a national framework of GP support with secure funding.
• There is much more to the care of drug users than prescribing methadone. Other effective interventions Home Office Addicts Index • As representatives of general practice, we regret the loss of the Addicts Index. We deplore the lack of consultation before the decision was taken. We recognise that the decision has been made, but we areconcerned that we have lost the possibility of checking if our patients are being prescribed for elsewhere,both for our own and our patient’s welfare.

We call upon existing regional drug databases to be improved and to replace the lost function and for them to
engage more with general practice.
1996 Consensus Statement

Managing Drug Users in General Practice ‘Why? How?’

• All GPs should offer General Medical Services (GMS) to drug users.
• All GPs should be willing to assess drug misuse problems and refer patients as appropriate.
• Where GPs take on an extended role in the care of drug users this should be resourced in recognition of the • There is an urgent need for training about drug misuse to be included in ‘core medical training’ at an undergraduate level. There is also a need for continuing medical education in this area for all GP registrars,GPs and hospital doctors.
Chairs Introduction to the Morning Session - Dr Claire Gerada

As morning Chair Dr Claire Gerada welcomed the third national conference to Edinburgh and acknowledged the
significance and value of having moved the event out of London. Claire spoke briefly of the great changes
once again facing primary care, and the changing NHS. She described entering partnerships as the name of the
game in moving towards a primary care led NHS. Questions still remain on how the broader changes to primary
care and the NHS are likely to impact on the development of drug and alcohol work responses. She suggested
that GPs and Primary care need to be considering now how best to place themselves to emerge from the
changes. Whilst the publication of the new Department of Health Clinical Guidelines had been delayed and
were not available for the conference, Claire was able to ‘speculate’ somewhat as to the likely general
framework of the document (see Section 7, p.22).
In line with other speakers on the day, Claire spoke of the positive impact general practice has had on the care
of drug users to date, and the growing opportunity and need for it to be at the centre of political, strategic and
operational developments in this field. One development reflecting this, was Claire’s own recent appointment
as Senior Medical Officer for Drugs and Alcohol within the Health Promotion Division of the Department of
Health. As the first ‘jobbing’ GP appointed the Department, this represents both a significant opportunity and
acknowledgement for primary care in the management of substance misuse. Clare is an organiser and leading
figure in the annual conference, a Lambeth GP who runs the Consultancy Liaison Addiction Service with over
150 users registered in her own practice, and a GP Commissioner for drug and alcohol services.
Claire welcomed and handed over to Mrs Nicola Munro, the Chair of the Scottish Advisory Committee on Drug
Misuse, for the opening address to the conference.
Welcoming Address - Mrs Nicola Munro, Chair of the Scottish Advisory
Committee on Drug Misuse (SACDM)

The welcoming address was given by Mrs Nicola Munro, Chair of the Scottish Advisory Committee on Drug
Misuse. She highlighted the concentrated problems in Scotland in which parallels could be seen across the UK.
This included the divisions and harm traditionally brought about within Scottish families through alcohol use,
now carried over into drug use. She praised an increasing and changing strategic response to drug use in
Scotland. GPs were identified as having a valued and increasing contribution through substitute prescribing, an
intervention which stabilises peoples lives and reduces their need to turn to crime to fund their habit.
She spoke of how high drug use in the 1980s combined with a high prevalence of HIV/AIDS led to sensible and
pragmatic responses from medical and other quarters. The 1990s saw this backed up by more structural and
strategic responses after the establishment of a ministerial task force and multi-agency advisory committee. The
formal and statutory establishment of Drug Action Teams (DATs) around the UK was echoed by other fora
working for greater co-ordination of service responses. This has been no easy task, but DATs efforts are
beginning to pay off, as they start to get to grips with delivering results within a national and local strategic
framework.
Scotland has recently seen the main political party leaders joined by other public figures in a high profile drug
awareness campaign. This delivered a conflicting but interesting dialogue which has probably left the
community more prepared to be open to the issues and more acknowledging of the expanding and changing
patterns of drug use. Scotland has seen prevalence studies beginning to adapt measurement technology to use in
less traditional areas of focus, such as rural and island areas. Mrs Munro drew attention to how with expanding
and changing drug use, whilst deprived city estate areas still remain most at risk, rural areas are now demanding
increasing levels of service provision. 1991-96 figures for Greater Glasgow showed a 1% risk of drug related
emergency hospital admission for the top social class. For the bottom social, class the risk was 28%. In North
East Scotland, problems and demands are manifesting, related to higher income heroin use.
Numerous aspects of changing drug use challenge the scope of services. We know of the increasing awareness
of drug related accidents and we know that children and young people are reporting increasing drug use
experimentation. Problems with teenagers with cluster risk behaviour including crime, social behavioural
problems, and drug and alcohol use are now well documented. Mrs Munro took the opportunity to support and
reinforce the need for effective drug and alcohol education in schools. At the other end of the spectrum, older
client groups with a long histories of complicated drug use, HIV, and mental illness are presenting in services,
whilst care and treatment within some prisons is still lacking. She felt this may in part highlight the need to
improve the effectiveness of programs which work towards abstinence goals; whilst we have lots of people
entering programs, we have many fewer people coming out the end of programs able to cope with a drug free
life. In response to a question regarding responsibility for care, Mrs Munro clarified her view that substituteprescribing as a treatment needs to continue in prison.
Mrs Munro stressed that we address what is behind current level of drug deaths in Scotland and the rest of theUK and look for ways to intervene. She highlighted the need for good information systems, particularly sincethe demise of the national addicts index. The central role of Community Pharmacists in the delivery of serviceswas emphasised as was the importance of involvement of user groups in improving services. She urgeddelegates to reach out and increase support and involvement of both these groups. Mrs Munro spoke favourablyof the opportunities offered by Scottish primary care trusts, together with the positive aspects of shared care interms of improved opportunities for communication, more accessible services and expansion of skill base. Shehighlighted how, if prevalence surveys are to be believed, all GPs are probably seeing drug users, if notdeclared, and affirmed how few other areas of general practice are so challenging yet so valuable to thecommunity.
Political Changes in Primary Care in England, Wales & Scotland and How
they Affect Care of Drug Users - Dr Susanna Lawrence

Dr Susanna Lawrence, is a GP working in a deprived area of Leeds, where she provides extended services for
drug users. Her work also involves her as a non executive member of the Health Authority and is involved in
the development of primary care groups. In terms of the political changes in primary care in England, Wales
and Scotland, she suggested that the new government papers have good and bad news for drug users. Her
caution was that general practice will have to be careful to maintain the focus and innovation around substance
misuse as changes are implemented, if it is to ensure accessible and appropriate services within primary care.
Dr Lawrence viewed the framework of the New NHS as intending to put patients first and improve care. Whilst
having some similarities with the internal market, she saw an improvement in that the new framework offers a
greater focus on equity, communication and openness. The NHS service framework will aim to unify budgets
and define new patterns and models of care with the intention of improving the consistency of care. There is
likely to be a ‘wait to see’ if Primary Care Groups allow the formation of natural communities or not, if
designated GPs for drug use evolve, how secondary care and primary care integrate, and whether or how GMS
and Hospital and Community Health Services (HCHS) budgets are pooled. Integration of secondary and
primary care services has the potential to both help and hinder service delivery. Interventions will need to cover
the broad spectrum of social and health, requiring effective training for all involved practitioners if
understanding and approaches are to dovetail. A question from the floor highlighted this with an example of
how a housing department, central in the welfare of drug and alcohol users lives, was working at loggerheads to
local treatment service philosophy. In this example, clients with drug and alcohol problems were viewed as
having self inflicted conditions, and a written policy deemed them unworthy of housing.
Dr Lawrence spoke of National Institute for Clinical Effectiveness (NICE) which show primary care to be
already relatively ahead in terms of effectiveness in working with drug users. Work conducted by the new
national guidelines committee and this conference network have begun to establish minimum national standards
of good practice. It was acknowledged however, that good practice standards may differ considerably from
what many GPs are actually doing in practice.
Although the green papers make mention of illegal drugs, she suggested that their focus on mortality indicators
(whether people stay alive rather than if people come off or make other changes) is too simple. She stressed
how important it was to ensure that the Government’s plans for the NHS (set out in the White Paper, “The New
NHS, Modern, Dependable” (4)) addressed the needs of substance users. She also prioritised the need to get
drugs and alcohol into the Health Improvement Programme (HIP) (5), which received formal support in one of
the consensus statements from the day (see Section 4, p.5). Significant differences with Scotland such as the
inclusion of mental health in Scotland and the English primary care commissioning role were mentioned.
How primary care conducts and responds to genuine community consultation is an area Dr Lawrence identified
as requiring urgent improvement. Public involvement needs to be more than just public meetings, which she
viewed as probably the worst method for effective consultation. However, accurately reflecting community
needs and wishes can present difficulties. Communities may be telling us they want drug users ‘out’ at all costs,
a clear conflict with the GPs responsibility to deliver good interventions for the whole community, including
drug users.
A similar difficulty may exist in addressing the culture of difference within the GP community. Numerous fears
exist amongst GPs around drug and alcohol client groups. These arise from the responsibility of delivering
care as well as the potential ability of these groups to be high consumers of local budgets. Extending the point
to budgets, deprivation and high need, Dr Lawrence made the point that financial equity is not same as health
equality. There are dramatic differences in areas, between densely and less densely populated areas even within
cities, making health needs assessments and equality of planned responses difficult. Responses are probablybest determined on local primary care group and city wide areas, but the divulging of budgets is likely to bedifficult and complex. Possibilities in terms of increasing the effectiveness of care delivery included the use ofdesignated specialist GPs, skill mix and greater use of other members of the PHCT as in fact the push of theWhite Paper suggests. GPs may not always be the best people for doing all of the work.
Progress Towards a National Network of GP Support - Dr Berry
Beaumont

Another exciting announcement, an idea grown out of last year’s conference and supported in this year’s
consensus statement, was the progress of a national network for supporting primary care in managing drug use.
Dr Berry Beaumont, a GP from Islington has become a lead in establishing the network after volunteering at last
year’s conference. She described how official policy over the last twenty years, particularly in a number of
recent policy documents from the Department of Health ( 6, 7, 8), has been encouraging and increasing the role of
GPs who have become major providers of care for drug users in Britain. However, support for GPs in this work
has been patchy, uncoordinated, poorly researched and poorly resourced. The consensus statements from the
1997 national conference on managing drug users in general practice said ‘There is a lack of and a need for
primary care based research on effective interventions and models of care’, and ‘Although there has been an
increase in support provided by specialist services, there is an urgent need to provide a national framework of
GP support with secure funding’ (9).
Dr Beaumont highlighted how we still do not know the numbers of GPs or patients involved in the management
of drug users in general practice, and how we have a patchy picture of the varied schemes and progress of
shared care across the UK. Even the core/GMS debate hangs in the air to some extent with the GMSC being
somewhat unsure on their position. Dr Beaumont reminded us how the forum from this conference, the growing
momentum of three national conferences, has organised itself and moved the national agenda forward. This is
represented by a regular dissemination of the SMMGP Newsletter, a book “Care of Drug Users in General
Practice - a harm minimisation approach” for GPs by GPs, conference committee representation on the new
clinical guidelines committee at the DoH, and now the benefit of Dr Clare Gerada being appointed at the DoH.
The time seems ripe to support this with a national network, to provide a framework of training, research and
support as identified in last year’s conference consensus statement.
Berry described how she had initially canvassed many GPs and London Academic departments, and she took
the opportunity to thank the many who had written and offered help. She eventually opted for the support of the
Centre for Research on Drugs and Health Behaviour (CRDHB) and drew up the proposal in conjunction with
Professor Gerry Stimson and Nicky Metrebian from the Centre together with GP and other colleagues. The first
outline proposal names the network as PRISM, but the search continues for a clinching name not already used
by other organisations. CRDHB was chosen because of its history of community focused research of drug use,
its strong links with primary care, and its academic independence from some of the larger established specialist
drug centres.
Berry describe the aims of the network being to establish a stronger national profile and support structure, both
operationally and politically, for GPs undertaking the work of caring for drug users. It would bring together
existing expertise and research, and facilitate new research into effective care in the general practice setting. In
addition the network would promote training and the development of adequately resourced shared care schemes
across the county. It would disseminate good practice guidance and encourage the representation of GPs in
local and national fora concerned with problem drug use. The network would be based at, and work in
conjunction with, the CRDHB in London, maintain an affiliation to the national conference network, and
establish formal links with the RCGP and other national bodies.
Objectives of the network:
• Support and encourage the GP role in working with drug users.
• Facilitate collaboration between primary care and other agencies.
• Promote research in primary care settings.
• Promote training for, and provision of effective care.
• Facilitate GP representation in fora concerned with problem drug use.
The activities in the first year programme of work would include:• Compile a research database and library of information • Regional meetings on current key areas of practice or research • Research workshops to provide advice and information on research in the GP setting • Develop links with existing primary care research networks • Compile a database of GPs working with drug users • Develop links with relevant local and national bodies concerned with training, policy and service An implementation group of GPs are working with CRDHB to obtain funding. Once established, the networkwould be managed by a steering committee of GPs and others caring for drug users in the general practicesetting. There will be elected officers to oversee day to day work together with a full time co-ordinator andadministrator. The steering committee will be able to be periodically extended or changed. Dr Beaumontextended an invitation to individuals to join, help or feedback ideas. The likely funding start date would be April1999. With the initial future funding yet to be decided, the on-going funding arrangement is still undecided, butthe possibility exists of it becoming a membership organisation, with a self financing capacity after its initialfunding period. Very positive support has been given from the DoH to date, although funding is yet to besecured. Dr Clare Gerada, speaking with her DoH hat on, supported the initiative and praised the very goodproposal format which she felt likely to get funding during the next funding round.
A suggestion was made from the floor, that the network liaises with the Society of Occupational Physicians as itis presently difficult to get clients and GPs to come forward in occupational scenarios. A question from thefloor asked how we address the need for the RCGP and the RCPsy. to work together towards supporting bothspecialist and GP competence. Berry said the RCGP has reviewed the proposal, and it is hoped there will beongoing RCGP involvement together with joint working with other colleges and bodies. However, as not allGPs look to the RCGP for leadership, the network would take a broader approach for developing support andcompetencies amongst GPs. A joint conference between the RCGP, the RCPsy. and RCN may be another stepforward.
Morning Session Discussion - Shifting Resources for an Integrated
Primary and Secondary Care Service

Discussion from the morning sessions focused on resourcing and supporting GPs in relation to shared or shifting
workload from secondary care. The point was made that national policy is not always a direct concern of ‘on
the ground’ GPs, but that the time and resource issue is, and that this has not been addressed. The concern is a
direct one, that if GPs are expected to expand services, a corresponding input of resources is required. Various
approaches for addressing this were discussed. Health Authorities are able to provide limited funding
originating from Tackling Drugs Together (10) which is managed through local Drug Action Teams. This may
be able to address minimum training requirement or go towards some recognition of GP payment. A little
known but undoubtedly more significant possibility is in HSG (96) 31(11) which allows Health Authorities to
vire money from secondary care into primary care where primary care can demonstrate competence to deliver
services.
The question was raised as to how often Health Authorities actually release money to primary care from
secondary services at present. It was suggested that the new Guidelines will give more clout to this possibility.
Recommendations were made for more lobbying of Health Authorities to recognise resourcing needs and
shifting workload and for the use of statistical arguments such as audited workload. This is an area that the new
GP network can engage in, as both national and local advocates for GPs. Clare Gerada also offered her support
from the Department of Health in addressing any problems around Health Authority resourcing between
primary and secondary care.
An example was cited by Dr Chris Ford of shifting resources and workload at Brent and Harrow Health
Authority. Here the process resulted in a re-tendering of specialist drug and alcohol services. The re-tendering
allowed some resources to be shifted to primary care, and for contractual specifications for specialist services to
be re-focused into supporting a primary care model of service delivery. In the given example, the problem
highlighted the difficulty large established and well resourced specialist services can have in voluntarily
changing their historical role, and willingly releasing or transferring clients who could be in primary care. The
dilemma for services wishing to work with primary care, is that this can be counteracted by a fear of reducing
client base and service role and relinquishing resources and power. The suggestion was made that tinkering
with services may be unlikely to bring about the real structural or resourcing adjustments necessary for an
integrated primary and secondary care model. More affirmative strategic and commissioning action, whilst
having its disadvantages, may be a more effective means.
The discussion also highlighted that at present, funding is often only available for methadone treatment. We
need to move away from this approach which supports a limited notion of what is possible in terms of working
with drug users.
What are Drug Users Rights? - Tam Miller

Tam Miller, a development worker at the Castle Project in Edinburgh and founding member of Chemical
Reaction users group gave a frank presentation on the issue of drug user rights and user involvement. This was
a stark reminder for the largely GP audience of how it can be to sit on the other side of the consultation table,
where a patient can be perceived merely as a ‘drug user’, and not a regular patient or member of the community
with legitimate health or personal concerns. Tam made the point that an employed person may come to the
surgery with flu symptoms and receive appropriate care, whereas a prescribed person with the same symptoms
may well be dismissed as simply withdrawing. Many stable users on scripts may attend for a variety of other
non scripting health concerns which may not be recognised. The script may be irrelevant to their reason for
consultation, and feeling unwell may not be related to their drug use. Many scripted drug users lead stable
lives, have families and mortgages, may work, yet often find themselves stereotyped by GPs.
The behaviour of a minority of users during ‘chaotic’ periods of their lives can influence the reputation and
treatment of others. An incident was reported of two scripted users talking at a surgery, where one was
questioned by the GP about the reason he was talking to ‘that junkie’. Complaint, by patients regarding GP
behaviour is difficult in any circumstance, but particularly when a script is at stake. GPs do hold considerable
power, which often engenders a reluctance for honest dialogue from the client, out of fear of losing the script.
This point was backed up by a GP in the audience who stated that ‘we get more respect back from patients than
we give’. Situations were described of GPs appearing to be overtly displaying or wielding power for power
sake, such as being inconsistent or petty in deciding when to strike patients off, or whether or not to issue a
script. Many users may consequently choose not to discuss with the GP, aspects of their drug use, such as using
on top. An amnesty by the Drug Problem Service in Edinburgh for users to say they are using extra on top and
not lose their script was welcomed as a positive development by users.
Tam spoke of the merits of starting up a drug users group. This may provide an opportunity for stable users to
get on with something productive in their lives which contributes something to society. Involvement may
include meeting and working with local GPs, the local drug squad, local authorities, or the media, towards
breaking down stereotypes and having a user voice heard.
A point was made from the floor, that it may be difficult for some users to talk in groups, and that not all users
wish to spend time with other drug users once their lives are stabilising. Groups were explained as being
usually mixed in terms of drug free and drug using members, where the group looks to support where each
individual is at.
Users Groups have a large network in Scotland, probably more effective than any GP network for working with
drug users. GPs and other authorities could learn from this model and be more open for meeting and working
with User Groups on an equal basis. A key message was the value user involvement has in informing GPs,
service management and commissioning and planning groups such as the Drug Reference Group or Drug Action
Team in the design and response of services.
The talk prompted an eager and useful question and answer session that resembled something akin to ‘All a GP
has ever wanted to ask a drug user but .’. Many topics were touched on including trust and the supportive or
punitive role of urine screening. Several views were expressed on urine screening, with Tam Miller describing
it as a disgrace, defeating any notion of trust. It was suggested that urines also offer the client the right to safe
care, a demonstration that the practitioner does care. In this context, screening should be used as a supportive
tool for developing trust both initially and randomly, where the client is free to openly discuss any use on top or
other issue. The sticking point seemed to be one of attitude or approach and how the urine screening is
presented and used.
One question was why patients are not more willing to come off methadone, which a GP from the audience
described as ‘horrendous’. Tam made the point that users have to fight hard to get and maintain a script, and
that once secured it stabilises and makes their lives more comfortable. Methadone was described as a drug that
sometimes receives unfair press, being blamed for deaths which in fact often result from alcohol mix and other
causes. Tam suggested that most users would agree that supervised consumption has had some success in
lowering the death rate, and that it may have an application with the user who consumes as many drugs as
possible from any available source.
Chair’s Introduction to the afternoon session - Dr Judy Bury

The afternoon was Chaired by Dr Judy Bury, well known for her work with primary care in Edinburgh who
affirmed both the value and challenge of hosting the conference outside London. She welcomed the many who
had come from all over the UK, and was pleased to see the event not so London dominated. She supported the
new national network proposal and requested support and involvement in the network, together with suggestions
for a different name than PRISM (currently used by other organisations).
Dr Bury praised the organisers in Edinburgh, at the RCGP in London and the members of the conferenceorganising committee for the enormous amount of work in both setting the conference up and running it on theday. She also thanked the many sponsors, both Health Service and commercial, for supporting the causefinancially.
Beyond Methadone - Dr Tom Gilhooly

Dr Tom Gilhooly presented on ‘Beyond Methadone’, highlighting the frequent reluctance by practitioners to
look at alternatives to methadone. Methadone has been established as the “Gold Standard” in opiate substitution
over the past 30 years and is now the most widely used drug in the UK for the treatment of drug misusers.
Despite this exalted position in the treatment of addiction, it still attracts a good deal of controversy and is
widely criticised for its toxicity and involvement in drug overdose deaths. Whilst a great advocate of
methadone, he felt it was unreasonable that a condition as complex as opiate addiction is being mainly dealt
with through the use of one drug and often one approach, namely methadone maintenance. Dr Gilhooly did not
downplay the value of maintenance or methadone, but advocated that GPs need to be on the leading edge of
trying different approaches, and targeting care at the early stages, for different types of patients, or at different
stages in an individual’s treatment.
Dr Gilhooly described the involvement of GPs in the treatment of drug users in past decade as probably the
single most significant factor in the changes in availability of treatment. He described how he and colleagues
together with the Health Board support and finance, had aimed to have 100 local GPs managing 2,000 users.
This has now been realised. Methadone is still a core treatment for GPs, but he regarded it as both healthy and
timely that new treatments emerge to challenge the supremacy of methadone. His review looked at some of
these contenders and the pros and cons of these treatments.
A variety of drugs were reviewed favourably in terms of possible targeted application in general practice. Theseincluded LAAM, diamorphine, buprenorphine, and benzodiazepines.
Levo-alpha-acetylmethadol (LAAM) has become available for prescribing in the UK this year (1998). As acogener of methadone, LAAM is an oral preparation and has advantages in terms of its long duration of actionallowing alternate day, or two to three day dosing. It is not safer in overdose but is cost effective. Concernsabout toxicity and the need for careful patient selection created licence difficulty for its trial in Glasgow. Manypatients in the American trials have been happy with LAAM and prefer it to methadone. There seems to be nodifficulty moving from methadone to LAAM that we know of.
Heroin has been used for a number of years in the UK but is no longer widely prescribed here for a variety ofreasons. Up until the mid ’60’s it was the most frequently prescribed drug for drug users in treatment. Themove towards specialist services providing care, increasing numbers of drug users, and frustration with themaintenance approach, created a shift towards oral methadone on a reducing basis during the ’70’s.
Diamorphine can be considered the drug of choice for most opiate dependant patients and can be used viainjectable and inhaled routes. Disadvantages include a short half life, difficulties in monitoring it, and thecurrent expense of delivering it as a treatment. The results of the Swiss heroin trials have been very encouragingand may lead us to reassess our policies here. With diamorphine, the best Swiss study shows 69% clientretention at 18 months. This was all the more impressive as many were methadone ‘failure patients’, includingthose who had failed with injectable methadone. Dr Gilhooly sees heroin as a tremendously useful drug, withgreat potential as a ‘move on drug’ for those who have failed with methadone. In response to questions from thefloor, he advocated intra-muscular use of heroin rather than intravenous for users who have no veins (painfulbut safer), and the need for heroin to be injected on the clinic premises.
Dr Gilhooly questioned the political, public, and practitioner concern of using heroin, when in fact it is a veryuseful and safe drug that is commonly used in hospital medicine. Legitimate limitations include that it isexpensive to deliver, has a short half life and is difficult to monitor. He felt that these can be more thancompensated for by the social and health benefits of its use as a treatment for drug users. Political pressure fromthe US to inhibit trials or change of policy together with present pharmaceutical production and pricing policiesare major factors in limiting its use. The promising Australian study has been downsized partly due to USpressure.
Buprenorphine, a partial opiate agonist/antagonist is becoming more popular as a substitution treatment,especially in France in the absence of methadone where the use of high dose preparations is being tried. FrenchGPs are not able to prescribe methadone without specialist support which led to a search for alternatives. Thesehigh dose preparations are not yet available in the UK. Buprenorphine has long duration of action and a goodsafety profile. In the form of Temgesic (low dose), it is easily injectable with serious health consequences, and has been the subject of some controversy. This potential to be abused, led to it being banned by the GlasgowLMC in 1990 with mixed results. Dr Gilhooly feels the decision was a bad one, as users have simply moved onto other drugs especially heroin, which may have greater risk. He sees buprenorphine as a relatively safe drug,safer than methadone, with the long duration of action being a big advantage, particularly to working people.
When combined with naloxone, studies show that users go into withdrawal if they inject this combination, buthave the opiate effect if it is taken sublingually - a real designer drug combination. He sees it as a potential starcontender for use in primary care settings.
When questioned on the subject of benzodiazepines, Dr Gilhooly said he would prescribe for clients duringwithdrawal as many seem to derive benefit, or for maintenance for regular street users as it offers many of theadvantages of other prescribed substitutes.
Drugs he perceived as having more drawbacks or limited application were primarily dihydrocodeine andnaloxone but include others such as hydromorphone implants, GA/naloxone, acuphase, lofexidine, clonedine,and buspirone.
Dihydrocodeine has been used for opiate substitution and has a chequered history with some strong advocatesbut little documented evidence of efficacy. He felt there was little positive to say about it as a maintenance drugIt has a short half life, a street value (often there is a fear of giving adequate dosage because of street value),and is difficult to monitor. There is little published evidence of its efficacy and it has been banned in theGlasgow Drug Clinic Scheme. It was stated from the floor that the first useful study on the use ofdihydrocodeine which shows some promising results was being published in the Drug and Alcohol Review[Macleod, Whittaker & Roberston. Observational study looking at 100 people on dihydrocodeine and 100people on methadone. There were no significant differences in outcomes over five years].
Patients have had little positive to say on naloxone and it tends to have poor compliance. However, whilst nothaving broad application it needs to considered for selected patients. In the US it has been claimed to besuccessful with alcohol users following detox. It is useful in alcohol dependence and may have uses with dualdependency. Some work has been done in the UK for post rapid detox from opiates. Careful patient selection isimportant.
Dr Gilhooly spoke of other drug treatments such as hydromorphone implant, and buspirone nasal spray. Hespoke of the use of tranquillisers in rapid detox such as acuphase and GA/naloxone combination as expensiveand yielding poor results. He commented though that he had heard one client suggest that paying £3000 helpssignificantly toward positive outcomes. He considers lofexidine and clonidine not useful in general practicesettings, although possibly having uses in in-patient care. He viewed clonidine as at least a cheaper drug thanlofexidine. This was not totally supported from the floor, as it was felt that both drugs may have their place forshort term users wanting a quick community detox without methadone. [Lofexidine is being used in London ina 10 day in-patient detox with 92% of users completing treatment. However, relapse seems high when used inthe community. Editor] In response to a question on crack use, he said that they did not yet have the experience of treating heavy crackuse in Glasgow and is unsure what approaches might work best. Sedatives may be useful for in patient andbuprenorphine may have applications.
In conclusion Dr Gilhooly said that we need to try different treatments for different types of patient, that careneeds to be targeted and that more focus is needed on rehabilitation. Beyond all these treatments are the almostuncharted waters of treating the problems that underlie the drug problem. He reminded us that effectiveprescribing is only the first step to recovery for patients.
What Research is There and is it Useful to Primary Care? Dr John
Macleod

Dr John Macleod reviewed the research available and its use to primary care. He argued that primary care is
currently the mainstay of the service response to problem drug use in the UK.
The scenario he described was one of rising drug use, rising costs, finite resources, and scepticism about the
effectiveness of interventions aimed at helping problem drug users. This, together with proposals to divert drug
users from the criminal justice system, will increase the burden on services, particularly primary care. How will
GPs and other members of the primary health care team respond to this challenge? Many are already reluctant
to engage with drug users for a variety of reasons. He argued that these challenges create a duty to patients to
use research effectively.
With the move towards evidence based practice, it could be argued that the addictions field is arguably one of
the most ‘evidence free’ areas of medicine. A small number of trials have suggested that in older opiate
injectors, motivated to change but unable to sustain abstinence, methadone mixture is more effective thannothing at reducing peoples use of other drugs and keeping them in contact with services. So is theresomething particular about methadone or would other drugs work as well? Can we generalise from these trials(some over 20 years ago conducted only on methadone, none in the UK) to our patients who may be young,poly-drug users, not necessarily motivated to change, not necessarily injection users? In an age of finiteresources could we achieve what we currently achieve more cost effectively? Evidence that might help usanswer these questions is thin on the ground and most of it comes from non-experimental observational studies.
Dr Macleod described ‘research’ supporting practice which ranges from grade A randomised control trial tograde D science free or experience debates, the latter consisting of pragmatic arguments where we are not sure ifwhat we are achieving is more harm or more good. Dr Macleod suggested however, that the evidence doesindicate that doing something is probably better than doing nothing, that methadone maintenance does work forolder heroin injectors, that the provision of other strong opiates (e.g. buprenorphine, diamorphine) probably alsoworks, and that generally the bigger dose (at a safe and correct level for the individual) the better the outcome.
A question from the floor asked what is the relationship between research and practice in terms of encouraginginvolvement of more GPs and raising standards. Dr Macleod responded that because we sincerely believeworking with drug users is ‘right’( that a GP should do it, and that it achieves positive outcomes), whenconfronted with a colleague who is sceptical and reluctant to engage with drug users, we tend to be economicalwith the truth about the size of our evidence base. This means that we can oversimplify and overstate whattreatment consists of and what it can achieve.
As to the broader question of how research relates to practice, Dr Macleod suggested that we are still in the newterritory stage of feeling our way. He elaborated that it is only recently that medicine as a whole has made anyideological commitment to being scientific (i.e. to practice based on research evidence) as opposed to scientistic(donning the mantle of science to enhance professional credibility and status).
What was also highlighted in this discussion, is that it may be a contradiction between what research suggests isgood practice and what is appropriate or acceptable within the public sentiment.
Statements were made about complacency around Hepatitis C and the urgent need for more research andinformation. Concern was expressed regarding the loss of the National Addicts Index on the possibility for datacollection. Clarification was given that in spite of the cost of the service, the system proved ineffective with onlyvery patchy notification. Concern was expressed around the fact that there are no clear plans to replace orimprove the index, although some local development work is being conducted on improving regional databasereporting and in developing other possible options and technology for the purpose. Dr Macleod suggested thatrather than lamenting the passing of a system for keeping tabs on addicts, we need to look at newer surveillancesystems that can be used in a health rather than a public order context.
Dr Macleod argued that most questions in the addictions field remain unanswered. We require more goodquality evidence as the basis for effective practice. Research at the moment does not tell us what to do withpeople whose drug problem extends beyond opiate dependence, or what treatments offer best ‘value for money’.
Whilst we know that long term opiate users benefit from methadone, this may not include the majority of drugusers presenting in general practice. Problems resulting from prescribed methadone diversion is not just mediahype and it is unclear with the absence of research how much the benefits of prescribing are mitigated by these.
Supervised consumption may have a place but it is expensive, probably not humane and certainly not a totalsolution. Whilst commitment to harm reduction is a worthy aim, questions remain around how we can helppeople to be drug free sooner. It would seem that systematic reviews of all data on community basedtreatments, improved information and monitoring systems, and imaginative high quality primary research ismuch needed to address the above.
‘Does our practice need to be evidence based or can we trust our common sense? If we wantsome reassurance that what we do actually achieves something positive, a good starting pointwould be a thorough appraisal of the existing evidence, published and unpublished. Earlierthis year a “ Drugs and Alcohol ” Critical Review Group of the Cochrane Collaboration wasregistered in Rome. Their remit will be the co-ordination and collation of systematic reviewsin this area. If we establish exactly “where we are now” hopefully what should also becomeapparent is “where do we go from here”.’ ‘In the meantime we will continue as medicine traditionally has, doing what seems humaneand sensible in the light of the limited evidence that is available and guided by our personalexperience and beliefs. This is not criticism of that approach, just a suggestion that it is astarting point, not a destination.’ [Conference abstract extract, Dr J Macleod] Chairs Closing Comment

Dr Judy Bury closed what had been a packed and exciting day by commenting on the evolving mood of the 3
conferences to date. She concluded that the focus is no longer on whether or not general practice should do the
work, but on a positive commitment to doing it better.
6. WORKSHOPS

Morning and afternoon workshops covered a broad range of topics some more political in nature such as giving
drug users a voice, shifting care and resources from secondary care, the role of the voluntary sector in running
specialist services, and heroin prescribing. More operational topics included alternatives to the Addicts Index,
getting going on research, setting up a shared care scheme, supporting the whole PHCT, training verses
competence, extending the team to pharmacists, and working with the homeless and working outside of the
inner city. Treatment options included lofexedine use and community detox, residential rehabilitation, talking
therapies, and benzodiazepine prescribing.
Morning Session Workshops

Each workshop was asked to report back a few key points from the session. These are listed below:

1. Shifting care or shifting costs. Setting up a shared care scheme -
Jean-Claude Barjolin

• Resources are needed to support shared care. These should not just be about GP payment, but should
consider support needed for the whole Primary Health Care Team.
• Treatment is not just about methadone. Payment or resourcing should not just be for methadone schemes.
• Both primary care and specialist services have a structural and attitudinal legacy that needs to be overcome to allow successful change for shared care.
• There is a need to view the whole package of change needed for shared care. If general practice is changing, secondary care also needs to change. There needs to be a vision of the whole system, with allparties involved in a dialogue which recognises a common programme of development.
2. Training verses competence - Dr Susanna Lawrence

• We need to concentrate on the majority aspiring to competence and not concern ourselves with a minority
who are not interested in this area of work.
• Competence requires definition. Those delivering services should be involved in the process of defining • We do not have a system or a successful approach for dealing with irresponsible doctors.
• There is a need to encourage structures for peer support such as local groups and the proposed GP network.
3. Regional Drug Misuse Database and other alternatives to the Addicts
Index - Peter Knight and Arun Sondhi

• There is a need for a future database index. A database can clearly produce useful statistics. A challenge
exists in finding a way of engaging professionals in seeing it of relevance and contributing data.
• A periodical follow-up on data supplied to a data base, whilst producing additional workload, would be • There is a need to develop common outcome indicators for all providers including GPs. This is a plea for standardisation of data for comparison over time and areas.
• We need to explore other alternatives to the Addicts Index rather than just considering adaptations of the regional database (which is anonymous data for reviewing trends) . Systems such as ACES (AddictsCentral Enquiry System) on display need consideration for the new approaches and technology that theycould offer.
4. Specialist services - statutory or voluntary? The role of the voluntary
sector. Why you need us - Sebastian Saville

• We need to stop stereotyping the voluntary and statutory sectors. GPs need the support of both the
• Do statutory specialist services need to be Psychiatry led? A voluntary sector specialist service headed up by a specialist GP may make more sense to shared care.
• If we are aiming at genuine partnership in shared care working, we need to be clear about the power and funding differences between many voluntary sector and statutory sector services.
• Concerns were expressed as to whether the voluntary sector can be professional enough. Is there a tendency for the voluntary sector to identify too closely with the client group? 5. Secondary Care and shifting resources - Paul Carvajal

• We need to move away from the primary/secondary care split and establish a continuum of care.
• Training, support and encouragement are priority aims for all services including specialist services.
• Rapid and equitable access need to be prioritised in non primary care services.
6. Widening the team. Working with pharmacists - Jane Pettifer

• Community Pharmacists want to, and need to be included as part of the extended care team. They have a lot
to offer in terms of client access and offering a multi disciplinary approach. Patients already value thepharmacist and chose to go to certain pharmacies. The overall GP responsibility for the client is supported,and not rejected, by this approach.
• There is a need for the development of instruments, protocols, contracts, and systems for named pharmacist involvement and local needs assessment involving all sources.
• The harm minimisation continuum should be extended from needle exchange to include other paraphernalia • There is a need for education and information sharing for pharmacists. Community Pharmacists can also • Concerns were expressed regarding pharmacy registers, confidentiality and information sharing. Police have access to pharmacy drug registers.
• Hand held records can be considered for accessing services - Even badges or ID have been developed in some areas.
7. Giving Drug Users a voice. Setting up a local drug users self help
organisation - Scottish Drug Action Group

• Health Authorities have an accountability to drug users.
• Employed or co-opted drug users can be involved in planning, delivering, evaluating or auditing services.
• User groups need to be supported by funding.
• Communication is both an up and down process. Commissioners, planners and providers would benefit as
much as user groups from more regular communication.
8. Working outside the inner cities - Andy Rome

• There is a need for on-going training and education for the differing needs of GPs and all members of the • Availability of services needs to be geographic and rapid. Service availability within 10 miles is acceptable.
GPs who will not provide services put an unfair burden on those who do.
• Communication is needed between all participants.
Afternoon Session Workshops

Each workshop was asked to report back a few key points from the session. These are listed below:

1. Community detoxification and the use of lofexidine - Dr Richard
Solomons

• Any detox needs good planning for assessing and supporting client motivation, social set-up,
follow up, and relapse prevention.
• GPs / primary care need support for lofexidine use from secondary care.
• Data on outcomes/relapse should be collected with any new addict index.
2. Pros and cons of heroin prescribing - Dr Roger Smith

• There are clearly both advantages and disadvantages to heroin prescribing.
• Half the group (6/12) felt there was definitely a place for heroin prescribing.
• Criteria for prescribing heroin need careful development.
• The debate needs to be widened out of the clinical arena. The Home Office Drugs Branch would benefit
from taking a more rational approach to the issue.
3. Talking therapies - Brian Whitehead

• There should be no compulsion on a patient to take up counselling. Compulsory counselling is a
• Practitioners who engage in ‘counselling’ should know their limits and be aware of resources available to • Everyone who counsels needs supervision.
4. Benzodiazepines - Dr Tom Gilhooly

• No one in the group was happy about prescribing benzodiazepines.
• There is little evidence based practice in benzodiazepine prescribing. Patient’s cognitive ability is known to
be adversely affected in those using high doses in the long term.
• There is doctor guilt which affects prescribing policy as the problem was initially doctor generated.
• The recommendation for those who prescribe, is that 2mg* tablets are prescribed.
[*The lowest dose possible. Editor] 5. Working with the homeless drug users - Dr Nat Wright

• GP practices need more support from workers attached to the practice in order to work with drug uses who • Rapid access and assessment is essential for drug addicts who are homeless.
• There needs to be more negotiation between GPs and support services of care plans and of the boundaries around issues of prescribing and housing.
6. GPs are not enough - supporting the PHCT - Caroline Jaquet

• To allow good Primary Health Care Team practice there must be strong team development and training.
• It is not clear whose responsibility it is to take on drug users. It should not be the GPs on their own.
• Teams should ensure that all members participate in the decision to take on substance misuse services.
7. Getting going on research - Nicky Metrebian

• GPs need space and time out of work together with resources and funding to be able conduct research.
• GPs need help to get the basic research question right.
• GPs also require on-going support and advise from national and local networks that have access to existing
8. When to suggest residential rehabilitation - Dr Gordon Morse

• Patients need to want abstinence and need to be well motivated. Detox should not be enforced or the
patient ‘bribed’ through scripting control.
• Residential rehabilitation provides an opportunity to the patient to remove themselves from their environment including time away from partners and other drug users.
• Failure is common with community detox.
• There is good evidence that residential treatment is useful and cost effective ( NTORS etc.).
National Clinical Guidelines

The Department of Health Guidelines on Clinical Management of Drug Misuseand Dependence During 1997 and early 1998 a working party chaired by John Strang, with Judy Bury, Dr Chris Ford and DrClare Gerada as members, has been meeting to rewrite and update the above guidelines. These guidelines werelast updated in 1991. There have been so many changes in the ‘drug problem’, the type of drugs used andtreatments since the previous edition, that the guidelines originally planned to be completed in late 1997, havebeen delayed several times.
Numerous questions have been raised during the production of the new guidelines. What is to be recommendedfor primary care? Is it time to broaden out treatment approaches from methadone as the dominant response foropiate dependent drug users? What other dependent drug users should general practice be treating and withwhat? Should the prescribing of injectable methadone be limited to specialists? Is there a place for heroinprescribing? How do we avoid spillage of methadone on to the black market and limit methadone deaths? Howshould shared care operate and who should take the lead? Dr Clare Gerada was able to speculate on the content of the new guidelines during her opening address as chair.
It seemed likely that the guidelines may suggest:• That all doctors have a duty of care for drug users, extended to provision of clinically effective treatment, such as methadone. The effectiveness of methadone, dihydrocodeine and lofexidine are likely to berecommended.
• Drug users would have rights to treatment and there would be no grounds for discrimination on the basis of • All doctors are to provide care for the general health needs and drug related problems whether or not the patient is ready to withdraw from drugs.
This supports and extends the 1993 GMC statement: ‘It is unethical for a doctor to withhold treatment from any patient on the basis of a moraljudgement that the patient’s activities or lifestyle might have contributed to the condition forwhich treatment was being sought. Unethical behaviour of this kind may raise the question ofserious profession misconduct.’ The guidelines are to advocate a harm minimisation approach, making advice on safer drug use available to allpatients seeking help. This is not sanctioning drug misuse, only limiting the harm caused by that use.
Care could be provided by doctors under 3 divisions: 1. Generalist - all doctors with contact with drug users2. Extended Generalist - medical practitioners involved in the treatment of drug misuse, although this is not their only area of work. They must demonstrate competence and may often work within a shared care setup.
3. Specialists - drug misuse is their principle clinical activity, working in a multidisciplinary team and Dose assessment facilities may become required, with recommendations that if facilities are not available, thatfunding need be provided. Supervised consumption may become required for newly scripted patients atCommunity Pharmacy outlets, with recommendations for resourcing this facility if required. Funding is likelyto be found centrally. Some recommendations are to be made on limiting leakage and deaths associated withprescribed medication, together with the need to show competence before allowing continuation of prescribingdrugs other than oral liquid methadone. The guidelines are intended to encourage practitioners to treat andprescribe safely, and could be possibly used in GMC investigations.
The new guidelines were intended to be out by ‘the summer’, but the most recent information suggests theautumn.
SCODA Training Package
The Standing Conference on Drug Abuse (SCODA) has been charged by the Department of Health with thecreation of a training package for GPs and other primary health care staff. This is being done in tandem with theclinical guidelines working party. A questionnaire was given to all delegates at the conference to ask what typeof training (lectures, CD ROM, leaflets, interactive small group training etc.) and educational content thedelegates would prefer. The data from this survey has been used to inform the advisory group consisting ofrepresentatives from some of the relevant primary care organisations and the voluntary sector.
At present the advert to initiate a tendering process for consultants or organisations to produce the trainingpackage is being written. It is hoped to pilot the paper based training package towards the middle of next yearand the electronic media later in 1999.
SMMGP - Substance Misuse Management in General Practice Newsletter
The SMMGP newsletter is now entering its third year and has just produced its 10th edition which is a briefreport of this conference. The mailing list has now over 250 recipients. All lead articles have been written bypeople on the mailing list about topics that affect primary care from a primary care perspective. Most of thecontributors have volunteered (some with a little encouragement from the editorial board!). We did hope torestrict it to two sides of A4 but it has recently doubled in size due to the wealth of information that is beingproduced.
‘Care of Drug Users in General Practice - A Harm Minimisation
Approach’

Judy Bury highlighted the ‘Care of Drug Users in General Practice - a harm minimisation approach’. publishedby the Radcliffe Medical Press in August 1997. The text is edited by Dr Berry Beaumont and has contributionby many organisers and delegates of the conference. It has its roots in this conference, and reflects a ‘for GPsby GPs’ approach.
North West London Combined GP Support Scheme
There is currently an initiative in at least three North West London Health Authorities which have existingshared care schemes, and several Health Authorities that would like to develop schemes, to examine thepossibility of a standardised substance misuse support scheme for GPs. This is currently in the initial discussionand proposal stage, but the areas being explored are: a centrally co-ordinated training scheme; a commonclinical auditing procedure monitored and reported by the North Thames Drugs Database; the development ofcommon good practice guidelines; standardised GP payments and cross boundary care; and reviews of specialistand primary care service structure, strategy and resourcing. The intention of the scheme would be to begin toimplement a common approach and protocol where possible whilst still retaining flexibility to respond todiffering needs and different service arrangements in different boroughs.
Primary Care Led Drug Services
There are an increasing number of primary care led specialist drug services which present a variety ofapproaches for supporting primary care and which deliver a range of innovative services to drug users. Thelargest is in the Wirral, the most formalised in Glasgow, and the most recent in Brent. These and many otherservices are addressing a re-balance of power and resources between primary and secondary services within acontext of integration rather than distinct specialisms. They also challenge the notion that specialist drugservices need to be psychiatry led, which has been the dominant model over the last thirty years.
8. EDITORS’ REMARKS - GOING FORWARD
The evolving mood of the conference seems to reflect a number of possible dynamics which could be summarised as: 1. Acknowledgement of a growing foundation of experience, knowledge, competence and commitment within the 2. A pragmatic vision of a way forward, and the creation of possibilities from the conference network for improving 3. A backdrop of significant changes at national/policy level which offer further opportunity for enhancing the care of A number of useful messages and recommendations have emerged from the 1998 conference. There seemed to be afocus and a ‘consensus’ within the core themes re-emerging throughout the many presentations, workshops and thediscussion during the day. These are best highlighted in the summary (p.4) and the consensus statement (p.5), but anumber of points are worth re-iteration.
The role of the GP in maintaining the health of drug users is of undeniable and significant value. Few other areas ofgeneral practice may be so valuable to the community, and is it seems like we have moved past the threshold of whethergeneral practice should be doing the work, into how it should be doing it, and the support needed for it to be mosteffective. There is much to be gained in the GP being supported in this work through more coherent efforts bothnationally and locally. Not least is the need for GPs to be supported in trying different treatment approaches, and forpractice to be supported by evidence and research. Whilst many GPs sincerely believe working with drug users is‘right’, that it achieves positive outcomes, it is only very recently that medicine as a whole has begun to demand morescientific rigour in generally raising the standard of treatment. An opportunity exists for primary care to be leading theway in an approach to care, evidence based medicine and service delivery. There is a positive commitment fromgeneral practice for improving the quality of treatment and access to services. What seems inspiring is that thiscommitment has taken the initiative for broader change, seeming for it to be possible to improve not only what isavailable to users in primary care, but also in the range of substance misuse services working in collaboration withprimary care.
Although the power of the conference comes from the belief that general practice can undertake this work successfully,there are still vast areas of the country and a significant proportion of GPs who are still unsure, frightened and opposedto being involved in this work. The conference and network must attempt to reach these other areas. Where changehas happened there has tended to be a scheme to support GPs. The most successful schemes have been GP initiated andoften GP led.
There has been an interest since the first conference in representing the perspective of drug users, with this being
reflected in a lead presentation. This is not tokenism but a sincere commitment to the belief that users need to be
involved in the process of change. Many of us have been more positively challenged by our patients than any other
party. This is now supported by the Government 10 year strategy (11) and in Scotland, by the formal mechanism for
user input to Scottish drug policy.
The Development of Primary Care and Specialist Services In order for primary care to effectively take on more involvement and responsibility, secondary care too must change.
The practice of specialist services and primary care working with poor communication or in mutual isolation needs tobe challenged. Primary care does need the support of specialist services, in fact we need them all the more, but theymust be accessible and responsive. They must begin to operate like specialist services in other disciplines, insupporting patients who cannot be managed in the community. At the same time primary care needs to normalise thetreatment of drug users on a more widespread basis. Specialist services would best focus primarily at initiating treatments which achieve patient stability, together with offering periodical interventions in patient treatment when thatstability is lost due to a change in life events, changing drug use etc.
The diabetic is well managed for most of the time in the community, but if the sugars become erratic or if they need tomove on to injectable drugs they are again stabilised by the specialist services. When the patient and the specialists arehappy with their management, they are again transferred back to care in the community. Why has it taken so long forspecialist drug services and primary care to be able to mirror this model.
For this model to work well in the drug field we must learn more about each other and grow to a greater understanding.
This co-operative working may well work best in a shared care framework, but this too must be accessible andresponsive and not become bogged down with bureaucracy.
Perhaps as well as continuing to get strong through these annual conferences, the network and the newsletter, we needto think more about joint working. Examples of this as suggested at this year’s conference, may be joint workingparties involving the RCPsy and RCGP, and a joint conference with all parties involved in drugs work. We now need tomake these a reality.
Editors:
Dr Chris Ford
Jean-Claude Barjolin

9. REFERENCES
(1) Tackling Drugs to Build a Better Britain. The Governments Ten Year Strategy for Tackling Drugs Misusepresented to Parliament by the president of the Council by Command of Her Majesty . April 1998.
(2) Health Service Circular 1998/065 ‘The New NHS Modern and Dependable. Establishing Primary Care Groups’.
NHS Executive.
(3) Health Improvement Programme (HIP) will be the local strategy for improving health and healthcare. Criteria forHIP are laid out in the Green Paper “Our Healthier Nation” and the Health Service Circular 1998/065 ‘The New NHSModern and Dependable. Establishing Primary Care Groups’. NHS Executive.
White Paper on HIP:
• The most important health needs of the local population and how these are to be met by the NHS and its partner organisations through broader action on public health.
• The main healthcare requirements of local people, and how local services should be developed to meet them either directly by the NHS, or where appropriate jointly with social services • The range, location and investment required in local health services to meet the needs of local people.

Green Paper on HIP:

• Give a Clear description of how the national aims, priorities targets and contracts will be tackled locally.
• Set out a range of locally-determined priorities and targets to address issues and problems which are judged important, with particular emphasis on addressing areas of major health inequality in local communities.
• Specify agreed programmes of action to address these national and local health improvement priorities.
• Show that the action proposed is based on evidence of what is known to work (from research and best practice) • Show what measures of local progress will be used (including those required for national monitoring purposes) • Indicate which local organisations have been involved in drawing up the plan, what their contribution will be and how will they be held to account for delivering it.
• Ensure that the plan is easy to understand and accessible to the public.
• Be a vehicle for setting strategies for the reshaping of local health services.
• That relevant statutory and nonstatutory organisations, patient and carer groups, professional groups, and the wider public have not only been engaged in the process of developing and consulting on the HIP and aresigned up to its content, but that the engagement has been “real” and “meaningful” and not tokenistic.
(4) Health Service Circular 1998/065 ‘The New NHS Modern and Dependable. Establishing Primary Care Groups’.
NHS Executive.
(5) Health Improvement Programme (see 3).
(6) Department of Health Circular. El (95) 114 Reviewing Shared Care Arrangements for Drug Misusers. NHSExecutive.
(7) The Task Force to Review Services for Drug Misusers. Report of an Independent Review of Drug TreatmentServices in England. Department of Health (1996).
(8) Tackling Drugs to Build a Better Britain. The Governments Ten Year Strategy for Tackling Drugs Misusepresented to Parliament by the president of the Council by Command of Her Majesty . April 1998.
(9) Barjolin J (1997) Conference Report: Managing Drug Users in General Practice. ‘Embracing the Diversity’ .
Royal College of General Practitioners. October 1997.
(10)Tackling Drugs Together: A Strategy for England 1995 -1998. May 1995. HMSO. London.
(11) Health Service Guideline (96) 31 ‘A National Framework for the Provision of Secondary Care Within GeneralPractice’. NHS Executive.
(12) Tackling Drugs to Build a Better Britain. The Government’s Ten Year Strategy for Tackling Drugs Misuse.
Presented to Parliament by the President of the Council by command of Her Majesty. April 1998.

Source: http://newsletter.smmgp.org.uk/download/rcgpconference/rcgp03.pdf

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