MEMORANDUM 25
Submitted by Dr Clare Gerada
INTRODUCTION
I am confining myself in this response to issues
that pertain to general practitioners, in particular where changes
in the law may or may not impact on the day to day working of
GPs. This has been written in my role as Primary Care Lead for
Drug Misuse Policy at the Royal College of General Practitioners.
The time scale needed to give evidence has negated the opportunity
for wide scale discussion, nevertheless this report has been shared
with other members of the RCGP, including the Chair, Professor
Pringle, and Honorary secretary Dr Maureen Baker and Dr Chris
Ford, Chair of the RCGP Sex, Drugs and HIV Task Group.
BACKGROUND
There are currently around 35,000 general practitioners
in the UK and around 19,000 of them are members of the Royal College
of General Practitioners. The RCGP is the Professional body overseeing
GPs, the body that represents its interests in relation to terms
and condition of work is the General Practitioners Committee,
which is a subcommittee of the British Medical Committee. To become
a member of the RCGP a doctor first has to undertake a minimum
of three years vocational training for general practice and then
take and pass the Membership Examination of the Royal College
of General Practitioners (MRCGP). Currently almost all doctors
entering general practice take the MRCGP.
General practitioners are in the main independent
practitioners, though recent changes in the NHS organisation has
meant that increasingly general practitioners are salaried—either
by a GP practice, a Primary Care Trust or other organisation—or
work as non-principals on sessional payments.
It would be true to say that there was no consensus
view around drug laws amongst GPs, rather as one could not assume
a single view from the population at large.
GENERAL PRACTITIONER
AND DRUG
MISUSERS
Over the years the response that GPs have made
to the treatment and care of drug users has changed. Whilst a
decade ago it would be unusual for general practitioners outside
the major conurbations to even come across a drug user, let alone
treat one, nowadays, most general practitioners would encounter
these patients in their day to day practice.
General practice is primarily concerned with
the improvement of health and harm reduction to drug users, their
families and communities. Drug use is a chronic relapsing condition
that general practitioners are well placed to deal with, being
the point of first contact for many users, families and carers.
The role of general practitioners has changed;
encouraged to a large part by official policy makers in the Department
of Health and also by bodies such as the Advisory Committee on
the Misuse of Drugs (ACMD). In recent years, the RCGP and the
GPC have reinforced government policy (see Annex 1).
Though strictly speaking general practice has
a very flat structure—with all assuming a generalist role,
in reality GPs, perhaps because of previous training, location
or interest, tend to have special interests, creating increasingly
formal levels of expertise within practices, localities and primary
care trusts. In the drug misuse field, three levels of expertise
are recognised and at the time of writing being delineated. These
levels are the generalist, the general practitioner with special
interest in drug misuse and the specialist. With respect to drug
misuse, all general practitioners will be in the first category,
perhaps 500-1000 in the middle and around 20 into the specialist
category.
The RCGP is currently developing a Certificate
in Drug Misuse aimed at equipping those GPs with the skills necessary
to provide a service to drug users at the GP with Special Interest
level.
DRUG POLICY
AND THE
GENERAL PRACTITIONER
The Department of Health has recently given
considerable resources to equip GPs with the skills, structures
and support necessary to see and treat drug users safely and any
new proposed changes in the drug policy needs to be mindful of
these changes.
In addition changes need to mindful that whilst
policy may advocate or make certain treatments more avail, this
does not mean that they will be delivered by general practitioners.
So for example, if heroin were to be made more available as a
substitute treatment for opiate addiction, there would be very
few general practitioners that would have the skills, facilities
or expertise to use this treatment safely.
In these situations, suggested licensing arrangements
being discussed at present which have been proposed by the Home
Office, would mean that no general practitioner outside those
that have positions in specialist settings, or those that can
clearly demonstrate they have the structures needed to reduce
diversion of this treatment, would be granted a license to use
it for treating addiction.
Furthermore, the logistics of using heroin as
a treatment in a primary care setting (especially as it has been
recommended by the 1999 Department of Health Drug Misuse Clinical
Guidelines that the provision of daily supervised ingestion for
the stabilisation period) would make it a very expensive treatment
and one that would have to be considered alongside other more
evidence-based, safer, cheaper and easier treatments, such as
oral methadone.
CONCLUSION
The current Drug Strategy fails in so far as
that the majority of resources are directed towards the Criminal—Justice
limb of the strategy with remarkably little to effect reductions
in demand or treatment. Primary care treatment is as yet still
undeveloped and resources are lacking for:
(a) sufficient training to equip doctors
to play a meaningful and continuous role
(b) money for effective prevention strategies
at primary care level
(c) research into what works most effectively
in primary care
(d) Mechanisms to reduce diversion, such
as effective supervised ingestion schemes.
Loosening the current drug laws without parallel
investment in the above areas would result in an increase in presented
drug use problems in primary care with a shortfall in the effective
means of addressing these needs.
October 2001
| 
