Hertfordshire Guidance
Substance Abuse

TREATMENT OF DRUG USERS IN HERTFORDSHIRE

Summary of LMC policy

Hertfordshire LMC’s policy is that the treatment of Drug Abusers, especially prescribing, should only be undertaken by those GPs who choose this ‘specialism’, are properly trained and accredited under HSG(31)96 and appropriately remunerated and supported by secondary care services.

Other GPs may wish to provide enhanced GMS care (excluding prescribing) to substance abusers, this is best undertaken by a Section 36 local development scheme for enhanced services.

Key Components of Policy

Training: It is essential that any model(s) developed have an effective and properly funded programme of training that would include:

Specific training modules for those GPs who wish to take on a specialist role in the treatment of substance abuse and, a training module aimed at enhanced general medical services for GPs who did not wish to get involved in the specialist care of substance abuse.

Accreditation: There would need to be proper approval mechanisms under HSG (31)96 for those GPs wishing to undertake the specialist aspects of treating substance abuse in recognition that the GP is undertaking a traditional secondary care role in the primary care setting.

A Commissioning Process: A process would be required for those GPs and their practices that want to undertake the treatment of drug users as a specialism, to be funded from HCHS money or other associated resources. The auditing of results and outcomes would be an integral part of the contract.

GMS Activities: Those GPs who wish to continue to provide GMS services only would need to be aware of responsibilities for appropriate advice and testing for HIV, Hepatitis B etc, and would not be expected to prescribe methadone. If there were additional services over and above traditional GMS which they were to provide for drug users this would be through a Section 36 Local Development Scheme. (PMS GPs could do the same via a variation in their contract)

Shared Care: Shared care arrangements are likely to involve a small number of practices that would be willing to undertake substance abuse work under a specialist contract. They in turn need close liaison with them for difficult cases.

IMPROVING THE TREATMENT OF PATIENTS WITH SUBSTANCE ABUSE PROBLEMS

AN INTEGRATED APPROACH FOR THE TREATMENT OF PATIENTS WITH DRUG ADDICTION

SECTION I

Drug Addiction – A National Issue

Successive Governments have produced policy documents, all of which recognise that drug addiction is a national issue. Statistics show that the number of patients registering for the first time with drug addiction is steadily rising. Most recently, the Reports ‘The Task Force to Review Services for Drug Misusers’ and ‘Tackling Drugs – To Build a Better Britain’ highlight the issues and require HAs/PCTs/LHGs to formulate local strategies.
The above Reports identify GPs as being the drug misusers’ most frequent point of first contact, whereas a smaller number of addicts with chaotic lifestyles may only seek treatment sporadically and as a temporary resident with a number of different GPs.
GPs are thus in an important position with this group of patients.
The level (and type) of drug addiction seems to vary from area to area both nationally and locally, as does GP practice policy even between neighbouring practices in localities with high numbers of patients with this illness. Generally speaking, such patients tend to drift towards GPs who are ‘sympathetic’. It could be argued that this has led to inequity in GP workload for these individuals.
The LMCs would support a more integrated approach to the care of substance abusers including:

	Specialist secondary care services who can assess and treat those patients traditionally described as ‘chaotic’ substance abusers. These include very young users, pregnant users and those injecting into neck veins. This is a consultant led service. These services need strengthening in some areas.
	GPs with a ‘special interest’ in substance abuse. These GPs have undertaken the diploma course offered by the RCGP (or equivalent) and are automatically ‘approved’ under HSG(96)31 to provide more specialised services, including the prescription of methadone to stable patients, and will attempt to assist patients withdrawing from maintenance. They can take appropriate referrals from the specialist services (and from other GPs), and can refer back to them when necessary. They may be supported by a team of named workers providing:
	a shared care support service. In some PCTs teams, including a Health Visitor, will work closely with those GPs with a special interest in the practice setting where they will maintain contact with patients.
	GPs participating in a S36 scheme for the provision of enhanced GMS/PMS to substance abusers. The rationale for this suggestion is developed in Section II.

SECTION II

LOCAL DEVELOPMENT SCHEMES

Introduction

In April 1998, a new GMS flexibility was introduced under the designation GMS Local Development Schemes. This flexibility is provided for in the NHS (GMS) Regulations 1992 as amended by the NHS (GMS) Amendment (No 3) Regulations 1997.

GMS Local Development Schemes give and PCTs the flexibility to improve the development and responsiveness of General Medical Services by giving local GPs financial incentives beyond those set out in the Statement of Fees and Allowances. PCTs can use GMS Local Development Schemes to provide services which help to address health inequalities and particularly in areas of deprivation, to enhance the development of GMS above that currently provided. Guidance issued in November 1997 under FHSL(97)43 provided details about the flexibility and gave examples of the kind of initiatives GMS local development schemes might cover. Local development schemes are funded from PCTs’ overall allocation, i.e. the unified budget. PMS practices can undertake similar enhanced services by a variation in their local PMS contract with their PCT.

What is a Local Development Scheme?

A Local Development Scheme is a scheme whereby payments are made to doctors in respect of GMS to the standard (or in enhanced ways) specified in the scheme. This takes the form of an agreement made at a local level between a Primary Care Trust and local practices. This agreement is made in the form of a local determination of remuneration for the purposes of the scheme and covers details of the service to be provided and the agreed targets/outcome.

PCTs must consult Local Medical Committees before establishing a local development scheme and before making or amending a determination of remuneration for a local development scheme.

Remuneration must not duplicate that paid from GMS cash-limited or non-cash limited/discretionary funds in respect of fees and allowances set out in the Red Book (Statement of Fees and Allowances), but can top these up where the SFA ceiling is less than 100% (FHSL(97)43).

The remuneration element of GMS local development scheme payments will be superannuable. Pension arrangements for payments made under the schemes will mirror those in respect of payments made under the SFA.

In 1999, Health Authorities were encouraged to invest in schemes which recognise the additional job weight for GPs inherent in providing services specifically to meet the needs of certain patient groups. To this end, "model" schemes have been developed covering quality provision for:

persons in nursing and residential care homes, and the very dependent elderly at home

physical care of severely mentally ill adults

drug misusers

homeless people

asylum seekers

The purpose of the model schemes was to assist Primary Care Trusts by providing ideas and examples of best practice when developing their own schemes for these patient groups. The models are not intended to be prescriptive but adapted to suit local conditions. PCTs can continue to use and develop locally devised schemes in the light of the policy documents in Section I, together with local health strategies for the treatment of drug addiction.

A LDS allows PCTs and local professionals to incentivise improved services for substance abusers and reward the additional workload of participating practices.

SECTION III

The following sets out the details of a Local Development Scheme under S36:

PCT MODEL LOCAL DEVELOPMENT SCHEME FOR THE PROVISION OF ENHANCED GMS/PMS TO PATIENTS WITH DRUG ADDICTION

1. Introduction

The purpose of this paper is to describe a Local Development Scheme (LDS) for the provision of General Medical Services to patients with substance abuse problems. It has been developed by the PCT in consultation with the Local Medical Committee.

2. The scope of the Local Development Scheme

Local Development Schemes are for the provision of General Medical Services. They allow for the enhancement of fees to individual GPs or to GP practices, where provision of services to a specified standard or in a certain way can be demonstrated. In the context of patients who misuse substances, practices are presented with additional complex clinical and social workloads, and are expected to work towards the following aims:

3. Aims

The aims of this scheme include:

To incentivise GPs to adopt a proactive and preventative approach to substance abuse.

The identification of patients who are suffering from substance abuse by participating practices.

The creation of a positive practice culture towards patients identified as substance abusing.

The active promotion of harm minimisation by the practice team.

The use of appropriate assessment/referral forms for accessing the specialist drug service, including referral to GPs with a special interest (appended).

The provision of appropriate health promotion services, e.g. immunisation, HIV/Aids testing.

The agreement to work as part of a wider team in order to reduce the incidence and morbidity of substance abuse and hopefully also the impact of aquisitative crime associated with substance misuse.

To encourage the growth of expertise so that more GPs may feel encouraged to train as ‘GPs with a special interest’ and undertake the prescribing and treatment of substance abusers.

4. Services to be provided to patients

The following are integral to participation in the scheme:

i) A designated member of the practice team (GP, Practice Nurse) to devote additional time to patients, either at first attendance or once a patient is admitted to the scheme. It is likely that 30 minutes will be needed. The aim would be to establish a baseline of knowledge and morbidity against which subsequent progress and improved health, and reduction in substance dependency can be measured.

ii) As part of this extended consultation, an assessment should be made of the patient’s drug usage, including:

- What drug/s is the patient using and for how long?

- Has the patient presented with this problem before, and when?

- Is the patient currently injecting?

- Does the patient have a history of injecting?

- Does the patient have serious forensic history?

- Does the patient have drug and mental health problems?

- Is the patient smoking Heroin?

- Is the patient using other opiates, e.g. Dihydrocodeine?

The examination would also include assessment of abscesses and deep vein thromboses when appropriate.

iii) A standardised assessment/referral form will be used (Appendix I) to refer the patient appropriately, if necessary.

iv) The patient will be offered ongoing support and contact within the practice, especially for health promotion, including the necessary explanations, investigation and treatment for associated medical risks. These interventions are to include, where appropriate:

- Hepatitis B and C status and immunisation if appropriate

- Cervical cytology screening

- HIV/Aids screening

- Contraceptive advice, including safe sex

5. Record keeping / monitoring

The practice should use standardised forms when notifying the Regional Database.

The practice should maintain a confidential register of patients who are considered appropriate for this S36 scheme.

The practice should record the numbers of extended consultations and patients offered Hepatitis screening and other health promotion measures.

The practice should record the number of patients referred to the secondary care service or a GP with a special interest for prescription of methadone or other substitutes.

6. Limits on numbers

The practice should not have more than 10 patients on a S36 scheme at any one time.

7. Training and practice facilities

The practice literature should make clear that enhanced services, excluding prescribing, are available to substance abusers and that they will be treated with respect and dignity, and all appropriate referrals made. Practice front line staff (Receptionists etc.) should all be aware of the practice’s positive policy and the details of what services are provided.

8. Remuneration

The LDS will be remunerated quarterly. The PCT will be mindful of the need to protect patient confidentiality in data flows for monitoring and payment purposes. The practice will provide six-monthly reports of the monitoring arrangements in section 5.

9. Quality and consumer issues

The scheme should be based on the monitoring of the performance of the provider and the service to demonstrate the relevance of the investment.

The PCT will wish to ensure that the scheme conforms with evidence based practice and that individuals contracting for and undertaking the tasks have undertaken suitable training and that the views of users have been considered.

10. Terms and conditions of Agreement

10.1 Applications should be made on the approved form (see Appendix II).

10.2 The PCT will consider favourably plans which involve more than one practice working in co-operation to achieve the aims of this LDS.

10.3 Practices will nominate a lead GP who will adopt responsibility for ensuring that the scheme is implemented effectively. (This lead GP could be the practices nominated lead on Clinical Governance.) All partners within the practice are to be in agreement with the practice taking on the Agreement.

10.4 The PCT will make the final decision as to whether to enter into an agreement with an individual practice based on information and documentation required by the PCT.

10.5 Throughout the term of the agreement, the PCT and the lead GP shall bring to the attention of each other any fact, matter or circumstance which is likely to have a material effect on the provision of services.

10.6 The PCT may at its absolute discretion satisfy itself that the lead GP has the ability to perform the services and may at any time throughout the term request further information and documentation from the GP for the purposes of monitoring the provision of services.

10.7 Throughout the term of the agreement the PCT may at its absolute discretion terminate the agreement following consultations with the Local Medical Committee. The PCT would only terminate the agreement after discussions between the PCT and the general practice involved have taken place with no satisfactory outcome. The agreement provides no legal basis under which the practice may take action against the PCT on termination of the agreement, as it is an Agreement and not a contract in law.

10.8 The agreement may be terminated by 3 months notice in writing given by either party to the other.

10.9 The PCT shall pay to the practice a sum of £**** per registered patient on the scheme as at 1^st April of the year for the provision of the enhanced GMS services.

10.10 Such payments will be made quarterly in arrears, to the account of the practice, on submission by the practice of an invoice to the PCT Chief Executive. On authorisation the invoice will be forwarded to the Practitioner Services Unit for payment.

10.11 Practices may apply to join the scheme at any stage (with the first quarter’s payment being adjusted accordingly).

10.12 Payment will be treated as Group 3 payments for superannuation purposes.

10.13 For PCAP Doctors wishing to participate in this LDS, a variation in their PMS contract will need to be negotiated.

11. Monitoring and audit

11.1 The practice must provide information to enable the PCT to monitor the progress of the Local Development Scheme.

11.2 The reports requested from the practice are not intended to be onerous and should be kept as brief as possible, whilst at the same time providing the PCT with adequate information to enable meaningful monitoring to be carried out. The details are included in Appendix II and III.

11.3 The scheme will be subject to post-payment verification checks by the Practitioner Services Unit (for example by checking medical records).

11.4 It is a condition of receiving LDS monies that practices are prepared to share best practice and assist other practices within the PCT to learn from their experience.

References

The Task Force to Review Services for Drug Misusers in England. DoH 1996

Tackling Drugs to Build a Better Britain – the Government’s ten year strategy for tackling substance abuse. The Stationary Office 1998

Drug Misuse and Dependence – Guidelines on Clinical Management. DoH 1999

Specialising in Treatment of Addictions, Gerada et al, BMJ Career Focus, 2 December 2000, p.2-3.

APPENDIX I EXAMPLE FROM LUTON PCT

Name and address of GP and surgery:

Name and address of patient:

What drug/s is the patient using and for how long?:

Has the person presented with this problem before, if yes when?:

The following questions are to ensure referral is to the appropriate agency
Is the patient currently injecting?

Does the patient have a history of injecting?

Does the patient have a serious forensic history?

Does the patient have a drug and mental health problem (dual diagnosis)?

If the answer is YES to any of these questions please refer to

If the answer to all these questions is NO

Is the patient currently smoking Heroin?

Is the patient using other Opiates orally, e.g. Dihydrocodeine, Suburtex (Temgesic)?

If the answers to these questions is YES please refer to

Date ______________ Signature ___________________

South Bedfordshire Drug and Alcohol Service

(SoBeDaS)

15-17 Cardiff Road

Luton LU1 1PD

Substance Misuse, Shared Care service (SMSCS)

94 Inkerman Street

Luton

APPENDIX II

GMS LOCAL DEVELOPMENT SCHEME

ENHANCED GMS/PMS FOR PATIENTS WITH DRUG ADDICTION

APPLICATION FORM

I/We (name of practice)………………………………………………………………………..

agree to provide enhanced GMS services for patients with substance abuse in accordance with the PCT local development scheme.

To achieve this we will be working with the following practice(s):

(insert names of partner practices – if any)

………………………………………………………………………….

………………………………………………………………………….

………………………………………………………………………….

Lead GP to sign on behalf of the practice:-

Signed: ………………………………………………………………….

Name: (please print) ………………………………………………………………….

Date: ………………………………………………………………….

Please return this form to the appropriate manager / lead PCT

APPENDIX III

GMS LOCAL DEVELOPMENT SCHEME

ENHANCED GMS/PMS FOR PATIENTS WITH DRUG ADDICTION

QUARTERLY REPORT

PERIOD ENDING JUNE / SEPT / DEC / MARCH 200…..

(delete as appropriate)

Date of this quarter’s clinical team meeting at which audit results and clinical issues were discussed and the implementation of this LDS reviewed

Names and job titles of personnel attending this meeting:

Please complete:

Number of patients on practice confidential Substance Abuse register

Number of patients reviewed in this quarter and on the LDS

Number of longer assessments / consultations this quarter for patients on the LDS

Number of Health Promotion consultations this quarter for patients on the LDS

Other comments on the running of the scheme, e.g. staff training, modifications to practice literature, GPs wishing to develop a ‘special interest’ in Substance Abuse. Any problems encountered in implementing the LDS.

I certify that the above information is correct and that the practice is providing the enhanced GMS for Substance Abuse described in the local development scheme.

Lead GP to sign on behalf of the practice:-

Signed: ………………………………………………………………….

Name: (please print) ………………………………………………………………….

Date: ………………………………………………………………….

Practice stamp:

Please return this form, within two weeks of the quarter end, to the appropriate manager or lead PCT.

(Draft Nov 2001, Dr Judy Gilley)