Models of care for treatment of adult drug misusers: Update 2006
As well as providing the core general medical services to substance misusers, a number of different contractual arrangements may be utilised to commission appropriate primary care-based drug treatments, including shared care, to meet local needs. These include:
Contracts for nationally enhanced services (NES) or locally enhanced services (LES) under the new GP Contract (nGMS) for GPs in shared care schemes with specialist support.
Nationally enhanced services (NES) for drug misusers have nationally negotiated specifications and payments, including requirements for GPs to engage in limited clini- cal governance activities and remuneration arrangements based on treatment modalities, which may be used if suitable
Locally enhanced services (LES) for drug misusers, which allow wide flexibility in determining service specifications. Many PCTs have negotiated LES contracts in preference to NES contracts, in response to an emerging evidence base on best practice, improved clinical governance and remuneration packages suited to a local context.
Personal medical services (PMS) contracts are another well- established mechanism for arriving at locally negotiated service level agreements. These can provide different levels of care, from simple prescribing in shared care arrangements to full packages of care delivered by whole teams from a primary care base or from separate clinics. PMS arrangements have been set up to deliver services to specific vulnerable patient groups, such as homeless people, refugees and sex workers. These services will be based in an established primary care base or a separate setting with a strong primary care ethos, and provide a range of services including drug treatment.
Either type of contract may allow for a GP practice to collaborate in a shared care arrangement with drugs workers who are either employed by specialist agencies, or for the more autonomous practice to employ such staff directly.
For more information on drug treatment and the new GMS (nGMS) contract, with NTA recommendations and consensus reached at a provider summit held by the NTA in December 2003, see the NTA website www.nta.nhs.uk.
Additionally, doctors with a primary care background may be employed by voluntary or non-statutory agencies, criminal justice agencies, or independent sector providers to provide a range of levels of care, with individually negotiated service level agreements.
3.5.3 Competences for doctors in primary care drug treatment
Commissioners should ensure local treatment systems have a complete spectrum of medical provisions to meet the range of
needs and the numbers of substance misusers entering treatment. This requires a variety of skills and competences at various levels, from simply providing general medical skills, to GPs offering less complex drug treatments, to specialist addictions skills and addiction psychiatry skills. This is a key message arising from the consensus document produced by the Royal College of General Practitioners and the Royal College of Psychiatrists – Roles and Responsibilities of Doctors in the Provision Of Treatment for Drug and Alcohol Misusers (2005)30 – as summarised in an NTA briefing note on its website, www.nta.nhs.uk. The consensus document specifies a hierarchy of roles for GPs, with increasing competency levels:
GPs providing core services. A doctor providing general medical care only to substance misusers
GPs providing enhanced services. A doctor providing basic medical care plus care to substance misusers, in accordance with locally agreed shared care guidelines
GPs with special clinical interest (GPwSI) providing enhanced services. GPwSIs have received specific higher level training in the management of substance misusers in primary care, usually the GP Certificate in Management of Drug Use Part 2. GPwSIs delivering locally enhanced services or nationally enhanced services are able to work more autonomously and take responsibility for more complex cases in substance misuse than other GPs
Substance misuse specialist (primary care). A doctor with a general practice background and an extensive postgraduate training in substance misuse working as a specialist GP lead or director employed by a PCT or mental health trust. These doctors are able to take on most complex cases, and where competences and accreditation allow, highly specialised areas, such as management of severe and enduring mental illness (in conjunction with specialist psychiatric support and appropriate clinical governance) and prescribing of heroin for treatment of addiction (under license). These doctors have responsibility for the full range of clinical governance activities and service development for substance misuse in their parent NHS trust. They are expected to have extensive postgraduate training in substance misuse, regular clinical supervision, CPD and peer support.
3.5.4 Models of drug treatment in primary care
A number of actual models of primary care drug treatment have evolved in the context of local resources and identification of need. These models include various types of shared care services in which GP services are supported by more specialist service provision, and primary care-led drugs services, which may or may not have shared care arrangements with a secondary care provider.