Too much at stake

steve brinksmanWe’re seeing the un­welcome return of the ‘postcode lottery’, says Dr Steve Brinksman

My practice has long had a reputation in Birmingham for working with people who use drugs and alcohol, and who are much more complex than those seen in most shared care practices. We were recently approached by the newly commissioned service to see if we would treat a man who – for a variety of reasons – wasn’t engaging with the main drug service. This has happened before and no doubt will again; as while a commissioned service is designed to deliver a good level of service to the majority of its clients, by virtue of commissioning arrangements it has to work within defined parameters.

So what happens when a client falls out with a service, or a service falls out with a client? It is a fact of life that we don’t see eye to eye with everyone and sometimes irreconcilable differences develop. In my experience, within drug and alcohol treatment this is frequently due to intransigence in both parties. However the service user can’t fall back on or blame ‘procedures’, ‘staff shortages’ or ‘we aren’t commissioned to do that’ statements.

Previously when drug and alcohol treatment was part of health services, a service user would usually be placed in an alternative treatment system, bearing in mind that access to NHS treatments should be fair, equitable and available to all. However since public health has moved into the realm of local government this seems to have changed.

All councils will commission drug and alcohol services but I suspect they are less willing to fund the ‘square pegs’ that may need to be sent to a different service. I have come across a number of clients now who simply fall through the cracks and, due to a breakdown in the relationship with the ‘only show in town’ are outside of treatment and, despite wanting help, they can no longer access it.

We are fortunate in Birmingham to have a number of highly skilled GP practices as well as the central service for drug and alcohol treatment, so it is usually possible to accommodate most clients who have a problem with one provider in an alternative service – albeit that a client may need to embrace change within themselves too, for the arrangement to work.

I worry about what may happen elsewhere in the country if this diversity isn’t available, how many people are excluded from their local treatment provider (for whatever reason) and are simply not able to find an alternative? And what should we do about it?

Steve Brinksman is a GP in Birmingham and clinical lead of SMMGP, He is also the RCGP regional lead in substance misuse for the West Midlands.