Kate Halliday, SMMGP Policy and Development Manager
SMMGP’s 2012 annual conference held recently in London was, as usual, well attended by a wide range of enthusiastic primary care practitioners and supporters of primary care based drug and alcohol treatment. The air of concern about the future of primary care based drug and alcohol treatment was, however, unprecedented.
SMMGP has heard of a number of shared care schemes being under threat of, or having actually been decommissioned. There appears to be a variety of reasons for this. Some schemes have been perceived to have failed to focus on recovery and to be ‘parking people on methadone’. Other areas, in a quest to simplify their increased emphasis on payment by results, have considered cutting primary care out of their model as this element introduces an additional factor into an already complicated model. SMMGP has also heard concerns that in localities which commission a single provider to deliver all services (including monitoring payment to primary care), the provider may perceive that it is easier and cheaper to run clinics from their ‘one stop shop’ services rather than to provide the support and infrastructure to primary care to deliver services. Some people at the conference felt that ‘shared care’ had become a ‘dirty word’ in the field of substance misuse representing ‘old school’, treatment which does not focus on recovery.
Primary care is well positioned to provide recovery focused services. National Drug Treatment Monitoring System statistics show that the treatment population of opioid users are aging and with co-morbid health problems and a large proportion are currently being treated in primary care. People in specialist services know how difficult it can be to encourage many clients to engage with their GPs to address health concerns. Primary care provides the added value of meeting health needs while addressing drug and alcohol problems. Health is centrally linked to recovery capital, as is the community based approach that primary care offers. Primary care understands the range of issues in its community and can link into local projects and resources, including mutual aid. It provides a local service, in a non stigmatising setting. It engages with families, both supporting the effects on family members with problem drug and/or alcohol use and improving the outcomes for the individual with a drug and or/alcohol problem. And in terms of the future, primary care will be an obvious setting for addressing pressing needs such as working with addictions to medicines, interventions for problematic alcohol use, and brief interventions and signposting for new psychcoactive substances.
But it is no longer enough to appeal to people with these arguments for primary care based treatment. In this changing political and policy environment it is time for primary care to evidence the added value that we can provide. Unfortunately the way that primary care is commissioned by most localities does not encourage us to do this. Most shared care schemes operate using Local or National Enhanced Service (LES/NES) contracts. Designed in 2004, they are woefully unfit for purpose in the current environment. On the whole, contracts specify payment for numbers in treatment and little else (although some areas are detailed and creative). And yet primary care has computer systems that are well equipped to provide evidence of health and wellbeing interventions, and does so regularly for other health conditions. If new contracts were designed to measure health and wellbeing outcomes and outputs, rather than simply count ‘bums on seats’ then primary care could excel at providing evidence for recovery focused interventions.
We need to act now. From April 2013, Public Health, newly situated within local councils, will take over the commissioning of drug and alcohol services via Health and Wellbeing Boards. This will mean an end to LES/ NES contracts as we know them, as contracting will take place directly between the council and primary care. This gives us an opportunity to influence the design of contracts that shows the added value that primary care can provide. Although Clinical Commissioning Groups (CCG) are not directly responsible for commissioning drug and alcohol services, they will continue to have a strong influence over commissioning decisions (particularly as they are likely to provide the solution to many of the alcohol interventions locally), and they will have representation on the Health and Wellbeing Boards. And CCG may play a crucial role in supporting the commissioning of community services that will support patients using drugs and alcohol, for example initiatives to reduce inpatient stays amongst vulnerable adults.
We need to begin raising this issue with commissioners in our localities, namely our Drug and Alcohol Team Commissioners, the incoming Police and Crime Commissioners, Public Health Commissioners, and Clinical Commissioning Groups. The localism agenda means that it is crucial for practitioners to influence the direction that services take, and now is the time to do it.
Watch out for my next blog post on moving towards outcomes in primary care based drug and alcohol treatment.
Is your area at threat of losing its primary care based drug and alcohol services?
Is your primary care based drug treatment service secure in your area going forward – and why?
Please contact SMMGP in confidence on: firstname.lastname@example.org