With primary care facing its severest set of challenges, delegates at the 2015 RCGP national conference argued vociferously for GPs to remain at the centre of substance misuse treatment.
The theme of this year’s RCGP conference on drugs and alcohol – now in its 20th year – was ‘the integrated future of primary care’. But what does this mean against a backdrop of widespread cuts and recommissioning, that in some areas means a reduction in shared care?
Dr Stephen Willott chaired a panel that aimed to bring different perspectives and open a debate with the audience, many of whom were GPs with a special interest in drugs and alcohol.
Opening discussion, Willott set the scene, describing a political situation where ‘tackling things for people who use drugs seems even less important.’ Welfare reforms were ‘one of the most worrying negatives’, he said, adding ‘A number of my patients are on sanctions, their benefits on ice.’
Jim Barnard of Inclusion Drug and Alcohol Services had worked for many years in shared care. He worried that the focus on completions threatened the capacity for building recovery capital, and lost perspective of the family.
‘Primary care has such involvement with families and service users – there are so many opportunities to get better outcomes,’ he said. ‘We’re facing a non-unified and disjointed system.’
Professor Oscar D’Agnone, medical director of CRI, said that in every country he had worked, drug treatment was political, but emphasised that ‘the focus should be the individual person’. This was a challenge, with shared care models differing according to local areas and commissioners’ views, but he said that most patients should be treated in general practice with services supporting GPs in dealing with the many complex issues around alcohol and drug use and mental health.
Nuzhat Anjum, head of strategic commissioning at Waltham Forest Clinical Commissioning Group (CCG) also acknowledged that these were difficult times, ‘and going to become harder’. But she brought a strong message on the need to work together to break barriers.
‘The worst thing a commissioner can do is ignore primary care,’ she said, while urging clinical colleagues to use their voice as ‘part of decision-making’. CCGs had a £63.4bn budget, she pointed out, with wellbeing boards having a senior position for a GP. ‘How do we use that?’ she asked the audience, adding ‘It is our responsibility to support each other, bringing together GPs, practice managers, helping each other. It’s not just about targets being met but about service users being happy. It’s an opportunity.’
Pharmacy services were another ‘really positive story’, giving scope for much wider services.
Acknowledging that money was tight, she highlighted a ‘real opportunity’ for joint bids with the third sector, and asked ‘are we exploring those areas?’
‘My suggestion is that primary care, GPs, commissioners and public health need to work much more closely together, minimising exclusions,’ she said. ‘If we do it together we can break it together.’
Sunny Dhadley brought a perspective from Wolverhampton Service User Involvement Team (SUIT), saying ‘It is our responsibility to help those that are vulnerable in our midst… there’s a lot more that can be done in terms of a joint approach.’
Targets didn’t necessarily make sense for every individual, with a holistic approach needed. But each service user had the capacity to unlock potential that could be ‘really cost effective’.
Dhadley reminded the audience that individuals had many complex needs – ‘we can’t expect people to be job-ready if there are other areas of their lives they need to address’ and asked, ‘are we providing things that’ll help people to be fulfilled?’
‘We hear the word holistic all the time,’ he added. ‘But if there are GPs who find this area of work challenging they shouldn’t be working with drug and alcohol users at all.’
After taking comments from the floor (one of which was a suggestion to produce a conference ‘mission statement’) Willott summed up the key themes, acknowledging the many concerns around erosion of shared care in many areas of the country and emphasising the need to reintegrate care properly.
‘We all have a responsibility to attack commissioning that’s going on and make sure it represents the most vulnerable,’ he said. ‘The message from this conference is that we can’t do it alone, but we can achieve it together.’
‘We’ve lost a really good shared care service – it’s been taken away from us. We’ve lost everything we’ve worked so bloody hard for…. Panel, you need to listen to what we have to say as we’re pissed off.’
‘The commissioning process puts GPs at a disadvantage. There are professional people doing bids. GPs need to put together a spec that covers all the points, including recovery.’
‘All this talk about an integrated future… GPs don’t have a voice – how can they influence decisions?’
‘Use your CCGs to raise these points. They have to be raised at the top.’
‘I wonder when people are going to stand up and say the focus on completions is totally unacceptable. It’s about time we stood up together and said there are a lot better things to concentrate on.’
Joss Bray, ‘ex-GP and troublemaker’
‘I’m a service user, I don’t give a shit who pays your wages. I’ve been in shared care for ten years – I wouldn’t be here if it wasn’t for shared care.’
Lee Collingham, Nottingham
‘The quality of commissioning is really patchy. Responsibility is being devolved locally.’
‘In the last five years things have gone into reverse; 100 per cent of people with drug and alcohol problems should be treated in primary care with the right support… management of drug users in primary care is rotting away.’
Dr Chris Ford, IDHDP
‘SMMGP is looking more at integration. We need closer integration with addiction psychiatry and are looking at building links with third sector organisations. We’ve not integrated as well as we could have done.’
Kate Halliday, SMMGP