Select Committee on Home Affairs Minutes of Evidence

Examination of Witnesses (Questions 940 - 959)



  940. Do you think there is a specific role for community nurses and other health professionals within primary care in all of this?
  (Dr Thompson) Certainly community nurses can get involved and in fact some community nurses retrain as drugs workers. I think the most important role outside the prescribing role and probably the most important role including the prescribing role is actually that of the drugs worker who is going to provide the relapse prevention work, the stabilisation work, and getting people back to employment and training while they are on maintenance prescriptions.


  941. Can you help me on one point, perhaps Dr Gerada can. Do the RCGP and the BMA not have a say in the curriculum of the training programme for doctors?
  (Dr Gerada) The RCGP will have a say in the postgraduate curriculum and it will have a position on the national bodies that look at undergraduates, but it is against competing interests and medical school training—and I am not an expert in this—which is choc-a-bloc. Anecdotally, for example, I used to teach at a medical school in south east London, an area with large numbers of drug users. I used to be given a day with them, a whole day in their five years. That was cut back to an hour and now it has been cut back completely. Every single doctor wherever they practise, maybe in the Outer Hebrides, will see a drug user and yet there is virtually no training in it. There are a few notable exceptions but virtually no training.

  942. How long does medical training last?
  (Dr Gerada) It is five years for an undergraduate and, to be a GP for example, you would add on another four to five years after that, once you have done your post-reg, your vocational training and a little extra on top of that.

  943. And you are saying that the training in relation to drug misuse might not last more than an hour?
  (Dr Gerada) Half-an-hour to an hour.

  944. Can I just put to you that, if this is the case, it is because the BMA and the Royal College have not pressed very hard for this to be given some sort of priority. Both of these are quite powerful organisations; they are not backwards in coming forwards when the interests of their members are at stake.
  (Dr Gerada) Again, I am not an expert on the educational committee of the RCGP. Certainly we are addressing this in terms of postgraduate education and, through a sum of money received from the Department of Health, we are trying to improve the generalist trainings and that is basic awareness raising for postgraduate level and also we have set up a five day training course of GPs. I would be most happy if this were looked at urgently in terms of putting it onto the undergraduate curriculum as a separate entity, not just as something which you might touch upon as you go onto the wards and see a drug user with a hole in their groin. What happens is that it breeds prejudice, it breeds fear amongst us all. The public do not know much about drugs; we see all the time that the public knows virtually nothing about drugs. How can they talk to their families about the problems of drug misuse if they do not even know the difference between crack cocaine and snortable cocaine?

  945. Would you agree with me that perhaps the professional association ought to be a little more vigorous in pressing for the training programme to take account of drug misuse which is such a large problem?
  (Dr Gerada) From the RCGP's point of view, yes.

  946. And from the BMA's point of view?
  (Dr Barnett) I would certainly have to find out a little more information which I am sure we will be able to provide for the Committee. What I would say is that, as you are probably aware, the training of undergraduates has changed or is changing and a number of universities are moving to a problem based learning approach and I suspect that certainly in medical schools which are in areas where there are a number of drug misusers, then because of the fact that the undergraduates are training more out in the community, they will come across more of these problems and therefore it will become part of their course.

  947. I would be grateful for that. I appreciate that to some extent you have been landed with this at the last moment but the attitude of the BMA in all this is a great black hole in this inquiry. I am mystified as to why it is has proved so difficult to obtain evidence from the BMA on what everybody agrees is a serious problem and I am not convinced that they are taking it seriously. Am I being unfair?
  (Dr Barnett) I suspect that you are being a little unfair because I suspect that there is a lot of interest generally within the BMA regarding the problem of drug misusers and the way they are handled. I am not exactly sure as to the approach that this Committee made to the BMA for the evidence that it wanted, but I will certainly take that back to the organisation and make sure that we can answer the questions you are posing.

  948. Would you agree that looking at the less than one page of evidence that the BMA has submitted after several attempts to extract something is not really adequate given the scale of the problem? It does not suggest that they are taking the matter all that seriously.
  (Dr Barnett) Not wanting to be unkind to the BMA itself, I suspect that my opinion was pretty much the same as yours when I saw the one paragraph that was submitted. I share your concerns and will certainly make sure that we do address any questions that we are not able to answer here in front of you now.

  949. May I ask the other two doctors why they think the BMA is so reluctant to engage on this issue. I notice that they grin to themselves each time Dr Barnett is struggling with the problem.
  (Dr Gerada) I think that the BMA have moved considerably on this issue.

  950. There is no evidence of it here, is there?
  (Dr Gerada) To be fair, you asked for only one page of evidence.

  951. Did we?
  (Dr Gerada) Yes, on the guidance that came.

  952. Nobody else has followed that instruction.
  (Dr Gerada) I am part of DrugScope and I know that we made great efforts and most of us ignored the brevity that we were asked for.

  953. One page would be an exaggeration for this particular piece of evidence.
  (Dr Gerada) The BMA have moved quite a lot on this issue. They represent, if you like, the trade union of general practitioners. I think they have been very angry in the past about work being dumped on general practice. It is said as a joke that next we will be doing brain surgery in general practice when they find out that the waiting list for that has been creeping up. They have been protecting our interests but I think there has been a shift.
  (Dr Thompson) I am actually still a member of the annual representative body of the BMA from last year and the arguments and discussions that take place to formulate BMA policy are reflective of the views of the membership of the doctors. It is true that that has changed over the last four or five years but, when the Department of Health guidelines first came out, there was a huge backlash which said, "This is a large amount of extra workload which has already been partially outlined to you and there is no money on offer and we are already sinking under the burden of extra work being shifted out into primary care." So it is not surprising that the BMA, while wanting to look at the problem of addiction positively, is not prepared to say, "Yes, we want to do all this and not get paid for it" when effectively what they need to do is protect the interests of the GPs.

  954. Should we regard this less than one page of evidence as a ransom note?
  (Dr Thompson) I do not know, you will have to ask the BMA!
  (Dr Barnett) I think that is being very unkind. I think that, in many respects, the BMA and the RCGP are not that far apart in the way that they want to see this problem handled, but it does have to be against the background of ensuring that there are adequate resources to do it, not just for GPs but for other drug workers in order that the problem can be managed properly. This is not a single person operation in looking after drug misusers, you do need a team approach if you are going to do it properly and I think that one of the problems is that, up to now, this has been seen as being bolted onto other general practice services whereas actually it needs to be looked at in a much wider field and not just at what is happening with GPs but in the shared care approach, making sure that you actually have a team of people trying to prevent problems escalating. In others words, when one comes for help, you can actually give them the help. One of the problems up to now is that, if you have referred them on to community drug dependency units, there are waiting lists which has meant that patients have had to wait six/nine/twelve months to be seen and then you have GPs trying to cope with the situation when there has been lack of training and lack of support for them and I think that is the message that is clearly coming over to this Committee, that one actually needs to make sure that there is a whole package on offer to enable patients to be cared for properly.

  Chairman: There is a good deal more that I could say about this but I will not, and that brings us rather nicely to the question of shared care.

Mrs Dean

  955. How useful and widely spread is the model of shared care?
  (Dr Barnett) Certainly locally, we have had grave difficulties in trying to introduce proper shared care and this has been really about trying to make sure that there is a co-ordinated approach. We have had schemes whereby there is supposed to have been shared care but there has been no continuity of care in terms of those people who have been helping GPs and, certainly locally, we have tried to set up a shared care system which would encompass all GP practices as well as all the various agencies, both voluntary and those within the mainstream NHS, in order that we can ensure that there is a standard quality of care that is being provided to drug misusers. However, trying to get that introduced has been difficult because of lack of those people on the ground who have the skills to be able to help GPs but you have to think that it is not just helping GPs with working out doses, it is actually looking at the wider care that is given to those drug misusers and therefore you have to look at probation services and you have to look at whether there is a problem with housing and what can be done to help them; so there is a much wider range that needs to be looked at. Certainly locally in Liverpool, it is in its infancy and I am not able to comment exactly on what is happening elsewhere, but I suspect that there will be a varying range from nothing up to very excellent shared care schemes across the country.
  (Dr Gerada) Having surveyed this about four years I think, the matter of shared care came and started with the 1990s and nobody really understood it. It sounds so magical, does it not? It just means co-ordinated care. When I surveyed health authorities—I can send you the paper—in about 1995, only one-third of health authorities had any formal shared care arrangement, and that was in England. That has changed. Again, it is a matter of the Government putting money where their mouth is. It has funded what are called shared care monitoring groups in each health authority which are now PCTs and PCGs and the figure has gone up considerably; so we have around 70 per cent of areas that have shared care monitoring groups, not necessarily shared care schemes. The quality of shared care varies and I have seen it from provider level from working in a street agency with the drug user rushing in, picking up a piece of paper to say that they have attended and rushing out and that is the shared care. There are obviously some places of excellence but we look at things as though there is something else going on which we imagine is very different. I think that shared care, when it works well, means care that goes beyond the simple exchange of a letter. Dr Barnett said that it is about caring for all other bits of the patient at any time that may be necessary. Compulsory counselling is out as well: this idea that drug users should have compulsory counselling before they get the methadone prescription. It has taken me sometimes five years to get a patient in the position where they want to start talking about their abuse. I think that if you train up everybody who is involved in providing the care and if we work together, at least we can start doing things for the patient's needs rather than through tick boxes.

  956. How do you get those patients who are reluctant to go to their GPs on board?
  (Dr Gerada) Again, there is significant evidence the other way round. I can send you the papers; it is in the literature. Patients prefer to access care through their general practitioner. The patients prefer it, it is more normal. This morning before coming here, I did a normal surgery and saw normal drug users in my normal clinic. They do not have to come with a sign saying, "I am a drug user" across their chest. Nobody knows. They can come and get their smear test or their ears syringed. They prefer to be managed. They certainly do not like GPs telling them to `bugger off' and `over our dead body', but I think we need to address it separately. You asked a question about what happens if you cannot access care. I think there is a serious problem with London resourcing especially as I think there are only about 60 specialists in England for a condition that is nearly as prevalent as diabetes if you think in terms of its long-term morbidity. Sixty full time specialists. That is ridiculous for 50,000 patients for such chronic morbidity and that is just drugs, let alone alcohol, tobacco and all the rest of it. With regard to patients who do not want to access shared care, I have yet to find a patient coming in to treatment who does not like what they get if it is provided in a holistic caring setting, which doctors are meant to do.
  (Mrs Glover) I was just going to say that with regard to shared care, where it works well is when pharmacies are included in it because the pharmacist sees the patient so often and has the opportunity to monitor and having an agreement before you start the programme that, if they want to say something to the doctor about the patient they can and, if the patient is not coping well, not turning up or whatever, the opportunity to link back in and complete that loop works better.

  957. Turning to drug prevention and education, how much involvement should primary carers and no doubt pharmacists have in that?
  (Mrs Glover) Drug prevention?

  958. Yes.
  (Mrs Glover) I think they can be quite useful. One of the problems for community pharmacy is that, if you have a good scheme that is working and you actually have patients in the pharmacy who are being supervised self-administration, it actually brings home to the local community that there is a drug problem. Sometimes the local community does not really like that very much, but it is a reality that it is out there, and I think the opportunity for pharmacists to be informing the public about drugs is fine. The problem is letting the pharmacists out to do that because they have a legal requirement to be in the pharmacy. Somebody has to pay them.

  959. So it is time and money.
  (Mrs Glover) It is money but legally you cannot leave the pharmacy. They cannot pop out for a two hour lecture; they have to leave somebody there to cover for them and that has to be paid for.
  (Dr Gerada) I can just say something about prevention which I think is very, very important. My first point is that you cannot help people if you do not know what you are talking about, so in terms of getting GPs to know what they are talking about, once they do that, then they can do harm minimisation and early intervention. Also in terms of prevention and again the Department of Health drug strategy has this, primary care is now delivering drugs education in schools. There are a number of schemes around the country in England, some working very well, some still embryonic, taking primary health care professionals who the children know, often since inter-uterine, if you can know anything, to form a trusting relationship. Not to go to five year olds and talk about drugs—we talk about brushing your teeth—but to build up a relationship during those formative years up to age 11 or 12 and not only that but if you can actually say, "I am your family doctor, trust me. If you get into problems, come and talk to me later on." There are schemes that are going on that have been put in through the implementation of the drug strategy which I think are vital, as is pharmacy. I talk about the pillars of society, things everybody can name; they can name their GP, they can name their supermarket and they can name their child's form teacher.

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