February 2012 |
drinkanddrugsnews
| 23
Soapbox |
Steve Brinksman
www.drinkanddrugsnews.com
Soapbox
DDN’s monthly column
offering a platform for
a range of diverse views.
There has been a lot of recent activity on the SMMGP website forums
in response to a
post from a GP who has been informed that the shared care service in his region is to
be decommissioned before the entire service is put out to tender, on the grounds that
it isn’t cost effective and doesn’t fit in with the recovery agenda.
We hope that this is an anomaly, because it seems perverse that after ten years of
encouraging primary care to become involved, some would now like us to return full
circle to when GPs were actively discouraged from working with substance misusers.
Those who trumpet abstinence for all as the only mantra, may see shared care as
synonymous with long term methadone maintenance and primary care as full of
people ‘parked on a script’, when in reality many primary care schemes offer a fully
integrated system incorporating harm reduction through to recovery and beyond.
The NHS is changing and this will no doubt have a huge impact on drug and alcohol
services. Two key messages are consistent: ‘moving care closer to home’ and ‘no
treatment about me without me’ and it is hard to envisage how these could be
delivered for those using drugs and alcohol problematically without significant input
from GPs and other primary care practitioners. The aims of the current drug strategy
also fit into a strong and robust primary care system, albeit that any system where the
GP is simply a ‘script robot’ will need to be redefined.
Recent figures from the NTA show a decline in the numbers of those entering
treatment, but an increase in the average age of those who do access help. We are also
seeing an ageing of the population in treatment. This highlights the problems of
working with people with co-existing medical problems, and the complexities this
brings make the holistic general medical skills of GPs more important than ever.
Transferring of commissioning to local authorities as set out in the
Liberating the
NHS
white paper could be seen as moving away from primary care services – however
the links between the GP-led clinical commissioning groups and directors of public
health will be essential if the vision of a truly integrated service is to be delivered,
especially with the increased focus on incorporating alcohol treatment. The scale of the
alcohol problem facing this country is immense and if GPs who are prepared to work
with substance users in current shared care schemes are disenfranchised, it is hard to
see how commissioners will persuade others to become involved. By the same token
the increased recent focus on addressing the importance of ‘addiction to medicines’ –
especially opiate-based analgesics and tranquilisers – emphasises the need for GP skills
to work with a group who would not necessarily perceive themselves as ‘addicts’.
Obviously not all shared care schemes deliver the high quality, effective integrated
services that are possible in primary care, but where that isn’t happening the answer is
to work with all the relevant stakeholders including the local clinicians to redesign
services to deliver these outcomes. Services that reflect best practice should be used as
exemplars to facilitate service redesign in other areas; the move to localism doesn’t
preclude learning from others.
At a recent event looking at redesigning primary care services, I was struck by a
comment from a service user that ‘recovery should begin and end in the community’.
GP practices represent the unique local communities that surround them and primary
care based drug services are therefore easily accessible. There is huge value in the
normality people feel in sitting in a waiting room with other patients as opposed to the
stigma of attending a ‘drug clinic’.
Primary care should be the hub that services link into, the default position for
people to be seen. This doesn’t decry the specialist work that goes on, it doesn’t
prevent those who need residential rehab from going, but it does need key workers to
see patients in that setting, to work with GPs to promote abstinent recovery as an
achievable aim for many and to be something to aspire to for those who are not yet
ready for that step.
I fervently believe that out of the shifting sands on which shared care currently
finds itself, we can create an innovative and inspiring primary care based system that
solidly integrates the best evidence from harm reduction, medically assisted recovery
and sustained abstinence, helping individuals to achieve and maintain their own
recovery goals.
Dr Steve Brinksman is SMMGP clinical director. www.smmgp.org.uk
SHARED CARE –
STIRRED, BUT
NOT SHAKEN
The skills of GPs are more
important than ever to the vision
of truly integrated healthcare,
says Steve Brinksman