‘Joining the dots’ was the theme of the Royal College of General Practitioners’ annual primary care conference. As GPs and health workers gathered in Birmingham to hear speakers examine the critical role primary care plays in working with drug and alcohol users, their families and carers, it became apparent that while the dots were being joined in many areas of clinical expertise, the overall public health picture was far from complete.
Would drug and alcohol treatment survive the maelstrom of competing priorities now commissioning had been handed to local authorities as part of Public Health England (PHE)?
‘We worry that our clients will be low on the priority list,’ a delegate told Anna Soubry, public health minister, in a session that she turned over entirely to Q&A. ‘In the last 20 years we have had improved drug services, but the top priority for politicians is potholes in the road.’
Soubry replied: ‘I have faith in local authorities to do the right thing. For example, teenage pregnancy rates are as low as they are, and dropping, because local authorities worked with health authorities. Drug services can be the same. The robust partnerships between many stakeholders, including police and housing, will help councillors understand that public health coming back to local authorities gives them both great responsibilities and opportunities for their local area.’
Rosanna O’Connor, director of alcohol and drugs at PHE, said that drug recovery and the alcohol agenda would be one of the top priorities that PHE would track and monitor on a regular basis. The joint alcohol and drugs function would include prevention, treatment and recovery and would ‘hold the banner for evidence-based practice’, she said.
With local structures ‘shaping up as we speak’ a key piece of work for PHE was to support local authorities in altering the behaviour of local communities.
But with many health and wellbeing boards prioritising alcohol over drugs, she warned of the need to be ‘mindful’ that ‘other public health priorities may prevail at local level’ now that the drug treatment budget was proclaimed ‘unringfenced’. ‘We need you to keep drugs and alcohol on the agenda of health and wellbeing boards,’ she said.
A workshop session on ‘commissioning in the new public health environment’ provided an environment for airing concerns.
‘Should we be dancing in the street at the chance to influence the localism agenda?’ asked SMMGP’s Kate Halliday, who chaired the session.
‘It’s time to fasten our seatbelts,’ said Gill Burns, shared care manager at Tower Hamlets clinical commissioning group (CCG). ‘Health and wellbeing boards have all been formed in different ways,’ she said. ‘They haven’t really firmed their agendas up.’ With different power bases in each area and the threat of more cuts to come, there was a risk that money could be moved away from patient choice. What was needed was a framework that meant the relevant voices could feed into commissioning reference groups. ‘It’s about getting smart,’ she said, ‘and thinking of integration and cooperation with our public health colleagues on things like sexual health and mental health. There are opportunities if we get smart.’
Jim Barnard, manager of Inclusion Drug and Alcohol Services, gave a provider’s perspective of the commissioning environment. Contrary to the expected scenario of more integration, simpler service specs, more focus on outcomes and the achievement of financial savings, it was a ‘messy picture’ in reality, with ‘massively reduced commissioning teams in some areas’, complicated service specs, and complete disregard of TUPE in some tender notices.
Other delegates added their concerns. ‘In Sunderland there’s no shared care – we’ve built informal shared care for alcohol,’ said John Devitt, CEO of Counted4 CIC. ‘Understanding of drugs and alcohol has disappeared from tenders and this is dangerous… it’s not joined up.’
Dr Joss Bray of the Huntercombe Group said commissioners were turning their backs on residential rehab as expensive, compared to daycare – the only option in the North East. ‘If you don’t want that, that’s it,’ he said. ‘What happens to people who need something else? It’s cheaper for local authorities to have deals with one or two providers to get a better price.’
Dr Anna Livingstone, a GP in Tower Hamlets, said welfare cuts meant many more families would be affected, accentuating the divide between ‘poor people and rich drug companies profiting. There are conflicts of interest everywhere – we need to be clear that our service users deserve services,’ she said.
Dr Tim Horsburgh, a clinical lead of adult services in Dudley, said it was important to be clear about the difficulties. ‘The amount of money in deprived urban areas is going to be reduced. An unringfenced budget for drug users isn’t going to fly very far. There’s local talk of evicting drug users – we’re facing a tidal wave that’s going to be very difficult for councils to cope with. Our service user council is going to find it very difficult to be heard.’
Pete Burkinshaw, skills and development manager, Public Health England, acknowledged the difficulties faced by a substance misuse sector that was ‘waking up to clinical governance and the importance of research’. Localism would bring ‘all kinds of permutations’, he said, with some areas having a ‘grossly inaccurate’ idea of their spending.
‘Local engagement is absolutely key,’ he said. ‘Take your seatbelts off and get out of the chair. Don’t let stuff happen to you, because the game is local – power and autonomy are in local areas.’
Integrating effectively with the new public health agenda meant acknowledging that public health colleagues had ‘different DNA’, he said. ‘Public health naturally goes upstream – they want to be mending the hole in the bridge, not hauling bodies out of the water. They’ve never been responsible for trawlers in the estuary before – we need to remind our public health colleagues about the trawlers.’
Despite the challenges, Burkinshaw believed that voicing such concerns was having an impact: ‘Because these things are said a lot, we’re starting to see embryonic change,’ he said. ‘We need to build on that.’
Mark Gilman, strategic recovery lead, PHE, saw public health as bringing ambition and aspiration to the world of treatment. ‘We know from public health that you are influenced by the people you hang out with. If you want recovery, identify someone in your network who’s already got it. Move away from the negatives – it’s like a barrel of crabs dragging each other down; misery loves company, and that’s what’s happening in areas where recovery’s not catching on.’
…Issue by issue
How can we engage with parents about substance misuse?
‘It’s difficult,’ said Prof Donald Forrester, director of the Tilda Goldberg Centre for Social Work and Social Care. ‘They often lie as they’re in denial or likely to minimise problems.’ Good practice required combining both cynicism and optimism.
‘I recommend you engage, focus, elicit, plan and action,’ he said. It’s all about building a relationship, building a plan and making people believe they can change.
‘You can’t make people change, so the key is to try and make people explore their own motivations. The more you push, the more people push back,’ he said. ‘Motivation is created in differences between your life now and the life you want to lead – seeing the difference between who we want to be and the life we’re providing. The skill is how you get people to do this for themselves.’
How can we provide sexual health services?
We need to communicate effectively with women of fertile age, said Rosie Mundt-Leach of SLAM.
‘One of the reasons we’re not engaging is we don’t want to give the impression that if you’re a substance user, you shouldn’t be having a baby. But it’s about delaying it until stability in drug and alcohol use has been reached.’
Educating women about the effects of drugs on their fertility would help to avoid unwanted pregnancy – and those who did want to get pregnant would benefit from advice on taking folic acid and giving up smoking.
Delegates in the sexual health workshop highlighted the difficulty of getting these services into different projects – and those that did often found it difficult to engage effectively. ‘Our clients aren’t ready to think about contraception. They think it won’t happen to them,’ said a worker at a homeless hostel.
Dr Bernadette Hard, a GP in Wales, said that all women should have easy access to impartial advice. ‘People in addiction are used to high-risk situations – when you’re injecting, your threshold for risk is much higher and acute intoxication makes women vulnerable to risky sexual practice.’
Practitioners also needed to be aware that treatment and support services – such as providing housing – was likely to increase fertility. On the plus side, there had been a cultural change, she said, with clients now embracing the fact that substance misuse services asked about contraception and bbv risk.
Dr Matthew Young said that contraception, bbv screening and smears should be incorporated in treatment as a matter of course and called for RCGP to incorporate easy streamlined standards in their management of drug misuse qualifications.
What should we know about foetal alcohol spectrum disorder (FASD)?
This condition is more prevalent than we realise, said Dr Shirrin Howell. Usually a hidden disability, it causes birth detects, commonly to the heart or kidneys, effects on the nervous system, and complex learning disabilities. ‘In talking about prevention, the advice has to be “no safe amount” of alcohol in pregnancy,’ she said.
‘If you adopt a child in the UK today, you are more likely to adopt one with FASD than not,’ said Julia Brown, CEO of the Foetal Alcohol Spectrum Disorder Trust (www.fasdtrust.co.uk). ‘We’re working in nice middle class areas, but 10 per cent of the pupils in two schools have FASD. It doesn’t just affect the poor, or those “over there”.
‘Don’t pigeonhole them – you will be coming across these children,’ she said. ‘We need to raise awareness and reduce the prevalence rate.’
The role of the family was a central theme of the conference, which gave perspectives from GPs and other experts, and families themselves.
‘Our families are one of the biggest influences in our lives – and now we’ve entered an era of extended families and relationships,’ said Dr Steve Brinksman.
There was plenty for GPs to look out for, he told the conference. Children in the care system were more likely to become drug and alcohol users themselves; parents needed help in challenging the stigma of being a ‘bad parent’ with a drug or alcohol problem; and how often did GPs think of asking patients with anxiety and depression whether it was linked to caring for a substance user?
‘Families should be a source of love and support,’ he said. ‘In primary care we’re uniquely placed to support not only the drug user, but also their family.’
Dr Leslie Ironside explained the effects on the child of living in a troubled family, and called on GPs to take ‘absolute interest’ in the children of their patients.
‘Reaching out and being accepted is crucially important and can be neglected. If there’s an adult that takes an interest in them, it can make a huge difference to a child’s life,’ he said. Toxic levels of stress could be very bad for children, whether from a ‘scare giver’, who exposed them to domestic violence, or a parent that didn’t give them enough attention.
‘A child gets an idea of what the world’s like from their parent,’ he said. ‘How can we get this person in a difficult place to trust the outside world?’
At a workshop on working with families experiencing substance misuse, Claire McCarthy of the charity 4children said that current provision for alcohol and drug treatment lacked a family focus. The charity’s survey with ComRes showed that a third of adults drank more than recommended, and 47 per cent were worried about the effects of drugs and alcohol on their lives. With alcohol a major factor in a large percentage of child protection cases, there was a lack of partnership working and funding, and the charity had recommended that the alcohol industry funded more support.
Two sides of the story
The conference heard from Steve, aged 42, and his father Alan (not their real names) who spoke about Steve’s 20-year drug history and its effects on each other and their family.
Steve: ‘It’s been a lonely journey but my dad’s been my backbone.
I’m about to go for a two-week detox. It’s been a long road for me to decide to do this – I hadn’t realised how far this life had gone past me. I lost my little brother to this lifestyle. I’ve been in prison. I’ve never had a bank account. One day I thought, ‘enough’s enough – I have to do this now’. My little brother died and the older one’s still using. My mum died when I was using. My dad’s been my backbone.
It’s been a lonely journey, even with support of my dad. When I first went to my local GP practice, I weighed nine stone. I look a completely different person now. I can be a person society can accept. I know there’s someone there to listen to me.
The daily grind of having to get up and shoplift, being wanted by the police, ducking and diving, not knowing what was going to happen that day, having no one to talk to. I started to think this was how it’d stay.
I realised, with my GP’s help, that you have to put the effort in. Every day on methadone I still wanted to use heroin. If I didn’t put the effort in, someone else would take my place. It’s not been easy and it’s still not easy. I’m still scared of what’s ahead of me in rehab.
Through everything I’ve put my dad through, he’s had no support. Sometimes I could see by the look on his face, he’s been relieved I’ve been in prison. I have to show my dad his hard work hasn’t been for nothing.
You need your family. Without my dad, who knows what could’ve happened to me. I know people not as fortunate, whose families have turned against them. Mine’s always had a bond with me and it’s important to have someone there for you.
There have been negative influences – brothers and partners. I had three kids with a non-user but that failed and every partner since has been a drug user. There’s no trust. It’s hard to get people to trust you – sometimes people don’t know the bigger picture. They treat you all the same. Sometimes though, you try and mask the situation – I didn’t want dad to know the whole picture.
Once I’ve completed rehab, I’ve been told there’ll be voluntary work. It’ll give me hands-on experience of nine to five. I’ve never had stability or a chance to prove I can sustain a proper lifestyle. I hope I’m not on any substance whatsoever by then.
I want to come out and see a direction for once – stay clean and have some stability. Have an address that’s secure, that’s mine.
For me, this rehab’s going to be a sanctuary – I’m going to grasp it with both hands and hopefully I’ll still have support from a drug worker who can point me in the right direction.’
Alan: ‘It’s been a never-ending nightmare – I’d like to see him helped.
I supported him all the time in prison. I found him accommodation time and time again and spent hours in courts. It was a never-ending nightmare. Visiting someone in prison, you’re treated like a criminal yourself, with fingerprints and sniffer dogs. It’s not very nice.
My three sons were addicted. We’ve never had a normal family. From time to time I was tempted to wash my hands of them. There were constant demands for money. I had to live at secret addresses. My elder son was very abusive. I’ve had no support. Eventually I went to our GP practice, but up till then I had no help.
After all these years, I can see light at the end of the tunnel. I have grandchildren and have 100 per cent hope that they won’t turn out like that. But I will never know how my sons turned out like they did. I brought them up in a good residential area and made them work for their pocket money.
Tough love doesn’t work – your heart rules your head. My younger son was involved with a drug service and we had to do a home detox for two weeks. It was horrendous. After a month, he was back on drugs.
Steve’s going into a six-month programme. When he comes out I’d really like to see him helped to find employment and somewhere respectable to live.’ DDN