Examination of Witnesses (Questions 920
- 939)
TUESDAY 15 JANUARY 2002
DR CLAIRE
GERADA, MRS
CHRISTINE GLOVER,
DR ROB
BARNETT AND
DR ANDY
THOMPSON
920. Dr Barnett, you are representing the British
Medical Association?
(Dr Barnett) Yes, I am. I am from the general practitioners
committee of the BMA; so I am interested in looking after the
interests of the 35,000 GPs who work within the primary care sector.
921. Do you have personal experience of dealing
with drug addicts?
(Dr Barnett) I am a GP in my own right and I do have
some drug misusers on my books. I am also involved locally with
the setting up of shared care guidelines for monitoring drug misusers
in Liverpool and I am also on the local monitoring group which
is overseeing that introduction within the city.
922. We have the impression, which may be unfair,
that the BMA is not all that enthusiastic about the subject. We
have had a lot of difficulty getting written evidence out of them
and, when it came, it was less than a page, most of which consists
of a description of the BMA's functions.
(Dr Barnett) I have read that as well and I would
say that what you have received is somewhat disappointing. I do
not think that is a true reflection of exactly what is going on
there. I think that, as I hope you will hear today, GPs do look
after drug misusers on their books and there is a varying range
of interest in providing care for drug misusers from those who
will not have any involvement to those who are obviously very
interested in the subject and I suspect that, depending on the
questions you ask, we will elucidate a little more on that.
923. Why do you think we have had such difficulty
engaging the interest of the BMA?
(Dr Barnett) I am not able to comment on that directly.
I only found out about this in the last week; so I have not been
involved in giving you any evidence so far.
924. You have been drafted in?
(Dr Barnett) Possibly but I am here voluntarily.
925. Mrs Glover, you represent the pharmacists.
(Mrs Glover) Yes, I represent the Royal Pharmaceutical
Society which is the professional body for all pharmacists. Pharmacists
have to be registered at the Pharmaceutical Society in order to
function.
926. So you are a closed shop?
(Mrs Glover) Yes, you can put it like that.
Chairman: Thank you all very much. Perhaps we
can begin with asking some questions.
Angela Watkinson
927. My first question is about the involvement
of GPs in the treatment of drug addicts in the primary care setting.
We have some estimates which were taken in the 1980s of general
practice involvement. I understand that about 50 per cent of all
drug users are treated by only five per cent of GPs, which would
indicate a certain reluctance to become involved. My question
is really about your estimation of the adequacy of treatment services
for drug users. May I just preface this question by a comment
of my own regarding whether treatment is even appropriate as the
term `treatment' implies an attempt to cure on behalf of the professional
health carer and a desire to get better on the part of the patient.
Is it treatment or is it simply supporting a habit? That is a
preface to the general question regarding the involvement of GPs.
(Dr Gerada) I think the survey that you quote was
published in 1985 which meant that it represented figures considerably
earlier than that. It actually showed that, if you looked at the
number of general practitioners at that time who were actively
involved in the care of drug users, it was about 10 per cent and,
of those, four per cent would have been prescribing a methadone
prescription. You have quoted the figure that 50 per cent of all
drug users were in fact being cared for by five per cent of the
GPs. So you can imagine that there was a ghetto-ising of drug
users into GPs' surgeries and this caused a number of problems
both to the patient and to the doctor. It put the doctor at risk
because, at that time, the average amount of training GPs would
have received throughout their medical school career would have
been about 20 minutes; they certainly would not have received
any after their medical school career. Therefore, most doctors
leaving medical school then and unfortunately now will have received
virtually no training in drugs general practice. The Department
of Health has currently commissioned—and I know that you
have heard this evidence from Professor Strang—a new survey
to see how the land is lying at the moment because, anecdotally
from someone who has been working in this field for about 15 years,
I know from my travels up and down the country that things have
changed considerably. I have met with and meet my colleagues and
I recently started a training course for GPs in England and, within
three weeks, we had 400 applicants and a waiting list of 100.
The latest figures—and this has not yet been published but
it will be published later this year and it has been spoken of
at a conference—show that 50 per cent of a random sample
of English GPs had seen a drug user in the last month and 25 per
cent of the total, so 25 per cent of the 100 per cent, had prescribed
methadone to a drug user; so a considerable change. Also, it is
not just the numbers of GPs as a percentage that has changed but
also the numbers of patients each GP is seeing. That has doubled
as well; that has gone from a mean of about two to just over four.
It is not only quantity—I think that, if we are talking
about quantity, we are heading down number ticking—it is
also that the quality of care has improved. In particular, I was
part of putting together the drug Misuse Clinical Guidelines which
has provided a framework for GPs with training at the Royal College
of General Practitioners and, with the support of the BMA, we
are changing the landscape in terms of primary care. I think the
evidence you have received up to now around general practice has
been from people who are not involved in the front line general
practice care and probably some of the evidence you have received
has been from doctors who have never been involved and are speaking
from their past experience in the 1980s and perhaps early 1990s.
(Dr Barnett) May I come in and say that, certainly
from my own experience locally, there are a number of GPS who
will not have anything to do with drug misusers. They do not want
it and they are worried about the disruption that it causes practices.
Of 105 practices, we know that 86 locally do have involvement
with one or more drug misusers on their placings.
Chairman
928. Are you talking about Liverpool?
(Dr Barnett) Yes, this is in Liverpool where obviously
there is a reasonable problem to do with drug misusers. Many of
them are happy to treat those misusers who have been their regular
patients but are not very happy with the concept of people in
effect cold calling saying that they want treatment. There are
a small number who are very interested in treating drug misusers
and there are a number of practices where the number of drug misusers
is in excess of 50 on the list. Obviously those doctors have had
specialised training and have the resources to care for them.
I think that the landscaping is changing but the fact is that
it would require a lot more training and a lot more resources
are needed if you actually want to increase those numbers and
that has to be taken against the backdrop of everything else that
GPs are expected to do. One of the other questions you asked was
regarding treatment versus just providing methadone. I would say
that the vast majority, again locally, are looking at it in the
concept of harm minimisation and therefore are providing maintenance
doses as opposed to actually trying to wean drug misusers off
the drugs. One or two of my colleagues locally certainly try detoxification
programmes. However, those do not appear to be that successful
in that the number of patients who remain drug free for any length
of time so far appears to be very short and I speak from my own
experience.
Angela Watkinson
929. Is that because of lack of motivation on
the part of the patients?
(Dr Barnett) I think that they are motivated but I
suspect that, once they are drug free and back out in the community
generally, they slip back into old habits presumably because of
the groups they are mixing with.
(Dr Thompson) If I could just add to what my colleague
said. In Birmingham, it is clear that a lot more resourcing and
training is necessary to support those who are already doing the
work. Many of my colleagues in Birmingham who are prescribing
methadone to addicts are doing so unsupported and this is why
the question of relapse comes about because, as GPs, we can prescribe
maintenance methadone and we can even reduce their dosage and
wean people off methadone, but what we do not have the time to
do is provide the social and counselling support that these people
need. Most of them got into drugs as a way of blotting out a history
of mental illness, of abuse and of social disenfranchisement and
that is the sort of work that drugs workers who we are now trying
to employ within primary care need to be able to do in order to
support what we are doing in getting them off street heroin. The
workload for GPs is immense. I look after approximately 40 heroin
addicts in my surgery single-handed. That probably equates to
my fair share of the total addict population in Birmingham which
is estimated to be about 15,000. My colleagues who are not happy
about prescribing methadone are not unhappy through a sense of
some sort of righteous indignation but rather because they need
supporting in terms of being able to assess these people and in
terms of being able to support them with the sort of work that
the primary care drugs workers would be doing. They are now interested
in training to provide the service because community drug teams
now have waiting lists of up to six months or more and their patients
are coming back to them desperate saying, "You have sent
me to the drugs services; I cannot get seen within six months."
(Mrs Glover) May I say something for completeness?
Chairman
930. Yes but I do hope that, throughout this
session, we are not going to have four answers to every question
otherwise we will be here all day.
(Mrs Glover) I was just going to say that there are
10,000 pharmacies spread throughout the country and we think that
around 75 per cent of them are managing methadone programmes to
a greater or lesser extent.
Angela Watkinson
931. My second question was about the role of
community pharmacies in providing primary care and in providing
general medical services and treatment in the management of addiction
problems to drug users and addicts including heroin addicts. I
wonder if you would care to expand on what you have just said.
(Mrs Glover) I would like to say that I think the
support that the pharmacy gives the drug strategy is enormous.
It does not get a mention very often. In fact, if you have 75
per cent of the pharmacies delivering these treatments and support,
I think it is really important that you recognise that many of
the pharmacies see these patients daily: they may see them three
times a week or twice a week. Actually, the greatest contact that
these people have with a health professional is with a pharmacist.
They see them 12 times a fortnight. Therefore, whatever the workload
is for the GP, it is huge for the pharmacist and it is an enormous
support. They are able to help them not only with giving them
their methadone but with their day to day health problems and
their families' health problems because you have to be able to
build up some sort of rapport in this situation to be able to
manage it, and I think that that plank of your pyramid of options
for treatment is a huge plank being supplied. I have to say that
I think there are some unsung heros in really deprived areas because
I have colleagues in Edinburgh who are dealing with 100 to 120
of these chaps a day.
932. What can be done to make that role easier?
(Mrs Glover) They need some sort of support and they
need a recognition that they are doing what they are doing very
well. They need a certain amount of funding. The chap with 100
a day has just put in two gun cupboards sideways on in order to
accommodate holding the methadone. It is additional cost and he
is not a salaried member of the health service; he is not able
to put a chit in for this; he has just put in the gun cupboards
because the police will accept those as secure locked-up cupboards.
He has done that out of his pocket because he needs to be able
to manage it. He has had to take on a second pharmacist and another
technician and he has to use a separate computer to manage the
whole process. They are doing a splendid job in very deprived
areas which are really difficult and I think they are doing very
well, but there is no recognition that that is what is happening
and the people who have the money in the DATs certainly do not
see pharmacy as an integral part of this or recognise the problems
that they have when they are managing this for them. In Berkshire,
they have put in a bid for CCTV for the pharmacies. Two of the
areas said yes, one said maybe and three of them said no. That
is what I mean about an inconsistent policy with regard to trying
to help pharmacies to deliver on this programme.
933. Is this for methadone taken on the spot?
(Mrs Glover) Some of it is. It depends where you are
as to how much of it is supervised self-administration.
Mr Cameron
934. Could I just ask one question following
on from my colleague. Do you have any figures for how many pharmacies
have been robbed or attacked due to having so much methadone on
site? The point you just made about safety and the role they play
for which they are unrewarded is an important one.
(Mrs Glover) I think it varies. It depends how short
they are of street drugs as to how much violence there is against
pharmacies. If there are plenty of drugs out on the street, then
the problem is much less.
935. It might be useful for the Committee if
your association could let us have any notes on the amount of
crime against pharmacies because of the costs of putting in gun
cupboards etcetera. What I wanted to ask you—and I think
this is probably for Dr Thompson and Dr Gerada—is to explore
a little more about why GPs have been reluctant in some circumstances
to engage with the whole drug treatment programme and whether
you think, in an ideal world, GPs should be the frontline service
for helping drug addicts or whether we should be looking at something
else. There are two ways: you can train all the GPs and they can
be the gateway to people going into treatment or you can have
a larger voluntary sector and larger treatment centres. Which
way should we go?
(Dr Gerada) May I begin answering that. You have to
remember that one of the problems historically about GP involvement
is not just the lack of training but, if you look back to the
1970s and 1980s and certainly the early 1990s, there was a discouragement
of GPs to be involved. There was the formation of drug dependency
units, community drug teams and street agencies. We then had—and
I am sure you heard this evidence—the threat of AIDS and
we had the threat of AIDS in the tail end of the 1980s when we
heard that the threat of AIDS posed a greater problem then the
threat of drug misuse. There was a knee-jerk response, ergo GPs
must start seeing drug users. Policy makers were banging on our
door, the ACMD was banging on our door saying, "You must
see drug users". This was at a time when, except for an exceptionally
few number of GPs, including myself, very few family doctors had
any contact with drug users at all other than to refer them on
to specialist care. So we had this policy drive and we had silting
up of secondary care services and the mantra of shared care, but
the mantra of shared care was not supported by resources and what
was happening on the ground was that untrained workers were advising
GPs about prescriptions, advising GPs to prescribe lethal doses
of methadone and, in several cases, patients did die and it would
be the GP in front of the Coroner's Court. We also in general
practice have similar problems to pharmacy: the considerable workload
and the fear of violence, and I would like to say that it is the
fear of violence because there is not actually in general practice,
when you look at it, any increased violence from drug users and
a well managed surgery could tolerate drug users and I suspect
a well managed pharmacist could quite easily tolerate it. There
are the time implications. We know that a drug user consults five
to ten times more than your age matched population. Remember that
we do not get paid for them. Pharmacy-wise, it is tied up in some
of the dispensing costs. The GP's per capita is something like
£25 per year—I am sure the BMA can correct me if that
is wrong—and that is the sort of fee you were paid for an
average young man, which most of these are. There are all sorts
of barriers.
936. Just to help the Committee in terms of
the big picture—I totally accept what you said about detail
and what has gone wrong in the past—let us say that I discover
that my flatmate is a heroin addict and he wants help. Where should
he go first? Should he go to his GP? If he goes to his GP, is
that where he should get the treatment or should the GP refer
him to a specialist unit?
(Dr Gerada) What I would say to you, Mr Cameron, is
that, if your flatmate had a drug problem, the only place you
would know where to access care would be your GP, your family
doctor, and we know that 90 per cent of drug users start off by
going through their GP's door. I think the big picture—and
I would not be here representing the RCGP and do what I did if
I did not believe it—is that because fundamentally general
practice and general pharmacy are a community based service, they
are the front door into treatment for drug users.
937. After the front door, do you think that
is where a lot of the treatment and methadone replacement, if
that is right, or diamorphine prescribing, if that is right, should
take place, that is the GP's surgery, or should it then be in
a community drug treatment centre?
(Dr Gerada) You are assuming that the two are separate.
I would say that the two services should be part of the same service.
It is a little like if you are a diabetic, you go off to see a
specialist. It is part of the same service. I think the GP, depending
on their skills and level of expertise, would do an assessment—I
think all GPs should be able to assess—and refer for what
is called dose assessment which is finding out what the patient
needs, then pass it back, and, when there are problems, they should
be able to pass back. It is a two-way process; it is the same
service. To look at it as them and us, primary and secondary .
. .
938. I did not mean that. I am just trying to
understand—
(Dr Gerada) The big picture is that GPs have a role
to play, there are certain patients who should be entirely managed
in specialist care as in diamorphine prescribing, complex medical
problems and complex mental health problems and I would imagine
that the vast majority of the patients can be and should be managed
in primary care which should be well recourced to enable that
to be done.
(Dr Thompson) May I add to that? I personally share
Claire's enthusiasm, but I would temper it slightly by saying
that this must remain voluntary work. General practitioners are
being encouraged to take on more and more work out of secondary
care and while I agree that this ought to take place in general
practice, there cannot be a position where GPs are being forced
to take over this level of care. Many of them are not trained
and do not want to train to take over this care and I see those
practices and GPs who are trained to provide this care—and
I hope that is an increasing number—actually doing this
side by side with the community drugs teams and, as Claire said,
just as some GPs are managing diabetes to what is almost a hospital
specialist level, some GPs will manage drug addiction to what
is almost a specialist level, but that is not a compulsory thing
and it needs to be properly resourced and properly set up.
939. What would you do in areas where you might
have GPs who did not want to get involved. In your submission
it mentions barriers to GP involvement: latent attitude to drug
users, disgust at injecting practices, lack of skills, concerned
by the legal status, which are perfectly understandable and we
have had them put to us by other witnesses. In those areas where
you have a number of GPs who do not want to get involved, what
do you do?
(Dr Thompson) You provide properly resourced community
drugs teams which are resourced adequately to meet the need of
the locality and I think the important thing is that if we actually
address this in medical school training, to which Claire alluded,
we will get a new cohort of GPs who are prepared to take on this
work but it must be properly resourced. It is an extra workload
outside of the core of general practice and we must realise that
the community drugs teams are going to have to take on some of
the responsibility of work which properly ought to be clinically
done in primary care but which is not going to get done in primary
care for the foreseeable future.
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