Published: 02/12/2004, Volume II4, No. 5934 Page 26 27 28
A lack of effective drug treatment has resulted in missed targets and adverse media coverage. One solution, says Rebecca Coombes, lies in training GPs
A national newspaper recently splashed with claims from a former Department of Health consultant that the government was deliberately inflating figures for the number of people in drug treatment programmes. Missing the target to increase by 100 per cent the number of problem drug users in treatment by 2008 was 'politically unacceptable, ' the anonymous source told The Guardian.
It is a story disputed by the National Treatment Agency, which is responsible for gathering the statistics. But there can be no doubt about the growing pressure to hit treatment targets - especially in the run-up to an election.
Yet a number of primary care trusts failed this year's halfway target - to increase the number in treatment by 55 per cent - and in some cases it cost them a star. Similarly, the HSJ Barometer survey of PCT chief executives consistently shows low confidence in achieving the Healthcare Commission's drug misuse key indicator target.
In the most recent survey, the panel of 100 chief executives gave themselves an average optimism score of just 6.56 out of 10 (page 23, 21 October).
The underperforming trusts appear to be struggling with basic problems such as poor data collection. Black-spot PCTs against the commission's key indicators include Erewash (a three-star trust) Chesterfield, Isle of Wight, Amber Valley, Sutton and Merton, and Swindon.
Of 10 PCTs that either failed or underachieved on the target, four were in the Derbyshire area.
A survey of high-performing PCTs reveals that success has come where the trust has tackled the issue head on and modernised their drugs service.
For example, Knowsley substance misuse Services commissioned a local university to find out the extent of local drug abuse (see box).
Joint PCT/social services commissioning manager Colin Vose says of the findings: 'Our substance misuse services were purely for opiate-based drugs because in the 1980s it had been a major problem and commissioning patterns hadn't changed. There were significant waiting lists.' Once clear about the problems, Mr Vose said the targets could only be achieved with 'robust commissioning arrangements, supported by investment in new services'.
A spokesperson for charity Turning Point says not everyone takes this apparently straightforward approach. 'Commissioning can be quite variable. We have some examples of very good evidence-based commissioning, but some could do with more support and training on how to commission strategically.
'Some PCTs do not engage very well with voluntary sector providers. They do not ask how services are working. They come to you and say 'this is the service we want, here's the budget'.
It is not a genuine partnership, ' he says.
Swindon PCT director of public health Jane Leaman says missing the treatment target at the end of last year was 'very difficult'.
It has, however, helped drive big improvements. She says that part of the problem was poor monitoring - the trust thought it was treating more patients that it actually was.
'We were counting people going through services different to those specified under the target. We had also included some people receiving support for alcohol because one of the services supports both drugs and alcohol. That wasn't allowed.' A census by the drug treatment monitoring service uncovered the discrepancies in January.
The trust has since agreed a new baseline on which it has to build improvements.
'We are working with service providers to make them understand what information we need. We have commissioned a needs assessment to better understand what services are required. We should soon have a clear picture so we can develop a commissioning strategy for next year.' Data collection problems are also cited by Jim Bosworth, joint commissioning manager for mental health at Sutton and Merton PCT. But a big challenge for Sutton and Merton was dealing with local GPs. He says: 'Although some local GPs already work in partnership with specialist community drugs teams to provide treatment, it was mostly informal arrangements, and only formal shared care arrangements contribute towards achieving the target.' The trust has now had meetings with GPs and agreed formal shared care arrangements via the general medical services enhanced services framework.
'While it will not happen overnight, we hope to see our efforts reflected in future performance ratings, ' adds Mr Bosworth.
A recurrent factor for PCTs that have hit targets is the ability to train more GPs to provide drug treatment. Royal College of GPs drug misuse training programme director Dr Clare Gerada says it is the only way for PCTs to succeed.
The programme has received£4m so far, although next year's funding still hangs in the balance. The course - the only one of its kind - has so far trained 1,000 health -28 27- professionals, including 700 GPs.
'It means that we haven't asked PCTs to fund themselves yet - GPs have had free places and a bursary. There will not be a bursary next year.'
Course for celebration
Dr Gerada is unequivocal about the course's benefits: 'If PCTs want to meet the treatment target they have to send GPs on this course - you can't do it any other way. It is not enough to say to GPs 'you must meet this target, sign more prescriptions'. I firmly believe this is the solution.' The programme has two levels. The first one, mostly done online, gives GPs basic training to deliver shared care services. The second level takes five months and is for GPs who want to deliver more specialist services.
Dr Gerada explains: 'The problem in the past has been that GPs have had on average 30 minutes of training about drug users in six years. This training is to enable them to do the work they should be doing, so they do not end up in front of the General Medical Council because of a patient death or to curb any maverick tendencies.' Training deals with the care of drug users and setting up services. It also looks at different drugs - for example, by holding sessions on crack-cocaine with recovering addicts.
Dr Gerada says there has been no shortage of professional interest. The college placed one advertisement for its training in 1999 and has never needed to advertise since. 'We have trained 1,400 people on one advert - it must be the most cost-effective advert of all time.' Dr Gerada says mentors go out to black spots to convince them of the need for GPs to be skilled up. She admits that those areas are often in the south of England, where drugs are not always recognised as a problem.
As an acknowledgement of patchy local treatment services, the Healthcare Commission has joined the National Treatment Agency to work out the best way to monitor the quality of services. It is piloting an inspection programme with drug action teams, with a plan to mainstream inspection in 2005-06.
'It is an opportunity for us to seriously engage with the health needs of substance misusers - a historically marginalised group with complex needs, ' says Marcia Fry, the Healthcare Commission's head of operational development.
This group is no longer so marginalised, especially when you have prime minister Tony Blair calling drug treatment 'the most powerful tool against drug misuse and associated crime'.
KNOWSLEY SUBSTANCE MISUSE SERVICES
The bedrock of Knowsley primary care trust's success in meeting the substance misuse target was a study done by the public health department of Liverpool John Moores University into levels of illegal drug use.
The study uncovered as many as 2,000 problem drug users in the area.
Joint PCT and social services commissioning manager Colin Vose says it provided the catalyst for a complete overhaul of the entire drugs service.
'We didn't just want to achieve our target, but to make a real impact. Before, we did the same one year as we did the last. We did not have the ambition to expand.
'Now we have told service providers that we are going to expand and not just to give a maintenance service, but we want people to get and remain drugfree.' Today the service has already increased the numbers of drug misusers in treatment by 100 per cent.
Key to Knowsley's success has been increasing capacity - expanding services to include crack cocaine users, for example - but it has also ensured rigorous performance management of services.
Each team has an individual target and has to file monthly figures on waiting times, numbers in treatment, successful discharges, number of needles given out, age of clients and gender.
Mr Vose says it is vital that staff have ownership of the targets. 'Part of the problem elsewhere is you have targets but no one explains how you are going to deliver it.
Staff need to have ownerships.
'We review services every six months and find out where the problems are. You have to keep an eye on all pathways to make sure there are no blockages.'
TRAINING IN NOTTINGHAM
Dr Michael Varnam (pictured), GP and clinical lead for substance misuse in Nottingham, says success in meeting the target requires a single enthusiastic person.
'It only needs to take one person who is an evangelist and then it grows. As a GP I see that drugs are destroying our cities and the curse of heroin and cocaine is harming individuals.' There are 15 GPs in Nottingham who have trained on the Royal College of GPs course - That is about 10 per cent of the city's GPs, says Dr Varnam.
'They are all working in practices seeing ordinary people in population as well.
The general medical services contract has helped as you get more cash; we have a drugs worker and a computer system to help them record data we should know about, such as sustainability in treatment and waiting times.
'In the past we have not been very good at getting people into treatment speedily, ' he adds.
'Our waiting list has gone from six weeks to 15 days - that is nearly a fortnight, so we are quite pleased with that.' He says GPs can offer a more flexible service than hospital clinics. 'If someone is an hour late or half a day late because they have been in trouble I can slot them in and provide an emergency solution.
'I can check on the computer and check that hepatitis C tests have been done, that we have given advice on safe injecting.' Nottingham City has also focused on the toughest end of the drug-abusing spectrum.
'We also want to target the illest in population - the prostitutes and street beggars, ' says Dr Varnam. 'My practice does outreach clinics, as part of enhanced GMS to target homeless and substance misuse.
'The drug teams go into the city centre with drug workers, nurses, a housing person and a needle exchange person.
'We are seeing the worst-affected people and offering a full care package.'
THE KEY TARGETS
Drug treatment is one of eight key indicators the Healthcare Commission will be using for next year's star-ratings.
The priorities and planning framework includes the public service agreement target to increase the number of problem drug users in treatment programmes by 55 per cent this year and by 100 per cent by 2008 (based on 1998 baseline). The framework is based on local delivery plans and monitored by the National Treatment Agency.
Next April the Police Act places a new duty on PCTs to work in a local crime reduction partnership, including a strategy for combating the misuse of drugs.
Find out more
National Treatment Agency www. nta. nhs. uk
Healthcare Commission 2004 performance ratings report
www. healthcarecommission. org. uk
Royal College of GPs courses
www. rcgp. org. uk
DoH guidance on substance abuse treatment
www. dh. gov. uk
Many primary care trusts missed targets for increasing the number of problem drug users in treatment .
Data collection problems were a major contributing factor to missed targets .
Training more GPs to provide drug treatment is the best way to increase treatment and meet future goals.