Examination of Witnesses (Questions 940
TUESDAY 15 JANUARY 2002
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
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 trainingand I am not an expert in thiswhich
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
(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
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
(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.
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 authoritiesI
can send you the paperin 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?
(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 drugswe talk about brushing your teethbut
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.