Beyond a script
Good quality shared care has always meant a lot more than just the provision of a prescription for opioid substitution treatment (OST). To help facilitate this our practice has developed a template that allows any of the doctors, nurses and key workers to update and review the situation with respect to a number of health outcome parameters for any client they are working with.
One of our longer registered clients, Danny, recently saw one of our GP registrars who, diligently checking the notes, realised that despite some years in treatment with us we had no record of his blood-borne virus status. A discussion ensued and Danny agreed to have this checked but he said, ‘no one can get my blood’ and of course he was right – despite years of experience our phlebotomist was unable to obtain a sample.
A few days later I was discussing this with the registrar during one of his regular supervision sessions and he told me that Danny had offered to get his own blood sample, but the registrar had felt that was inappropriate. The opportunity to explain the need for pragmatism in working with this group wasn’t missed and Danny was duly invited in.
After being provided with sterile equipment Danny proceeded with a very proficient femoral stab and we soon had the sample we needed. We booked a follow up appointment to discuss the results, as it is our policy to always give BBV results in person, whether positive or negative. The results came back showing he was hepatitis C antibody and PCR positive and it was a genotype 1 infection.
As part of the suite of training resources available to GPs, the RCGP has a part 1 and a part 2 course in viral hepatitis. The former is designed as a general introduction to the subject and is invaluable for those working in shared care to be able to give patients with hepatitis C the information they need about the illness and treatment options. The part 2 course was only launched this summer and is much more intensive. I was lucky enough to be in the first cohort to complete it and over the course of the six liver outpatient clinics I attended, have built a good working relationship with our local hepatologist.
I was able to reassure Danny that the fact he was receiving a methadone script was not going to prevent him accessing treatment and in fact addressing his daily alcohol consumption of three cans of strong lager was much more significant. I was able to explain that alcohol not only accelerated the progress of viral hepatitis, but that it could reduce the efficacy of anti-viral treatment. He decided to think about it and when I saw him a month later he had reduced his alcohol and was keen to be referred.
Having undertaken the RCGP part 2 course I now believe that there is a developing expertise within primary care, which could help facilitate community-based treatment programmes for hepatitis C. A huge barrier to accessing treatment for substance users is the difficulty in frequent hospital outpatient attendances – something far more easily addressed in primary care.
A move towards making shared care more outcome focused should encompass the impact of viral hepatitis, and by looking to increase the provision of services by taking the process closer to patients we can support those many thousands to whom treatment services currently seem an impractical option.
Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP. www.smmgp.org.uk. He is also the RCGP regional lead in substance misuse for the West Midlands.