PRIMARY CARE
BETTER PRACTICE
The last 25 years has seen the treatment of people with substance misuse issues in primary care change beyond recognition , hear delegates at RCGP and SMMGP ’ s annual conference
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GPs said , “ You can treat their abscesses but don ’ t talk to them , because they ’ re deceiving and they ’ re liars ”,’ Dr Chris Ford told delegates at the 25th RCGP and SMMGP Managing Drug and Alcohol Problems in Primary Care conference . She was describing the situation when seeing her very first patients with substance misuse issues as a trainee in Kilburn , north west London . ‘ And all the books were very much psychiatric-led and about how this is a mental condition and you ’ ve got to keep people under control .’
When she and her colleagues first proposed the idea of a primary care substance use conference , however , the RCGP were ‘ incredibly supportive ’, she said – ‘ although they might have thought we were a bit mad .’ Treating substance issues was now a normal part of general practice , she stated . ‘ But back then it wasn ’ t , and I think through the network and the conference and SMMGP we ’ ve mainstreamed these ideas and normalised care of these patients within general practice . And that ’ s really important .’
‘ What an amazing achievement – 25 years of the conference and 25 years and more of SMMGP ,’ added Dr Clare Gerada . ‘ The conference was set up because at the time GPs had signs on their doors saying things like “ no drug users treated here ” and intravenous drug users were dying all over the place .’
The conference had challenged commissioners that more could be done to reduce drug-related deaths , said chair Dr Stephen Willott , and that money spent on drug and alcohol services offered ‘ such a good return ’ on investment . ‘ But actually it ’ s the right thing to do – to look after the vulnerable . Ultimately drug use is far more of a health issue than a criminal justice issue .’
April Wareham ’ s speech as director of Working with Everyone demonstrated the central part now played in the event by people with lived experience . The project work of her organisation fed in from ‘ all sorts of disparate communities ’ and conveyed the message that people wanted better treatment , whatever their circumstances . ‘ It ’ s not just about drug use , but about many other needs ,’ she said . But everyone needed access to good healthcare .
This year , with COVID ‘ at the front and centre of everyone ’ s thinking ’, everyone had been talking about inequalities , and we needed to ‘ be specific about which inequality we are talking about and who is affected by it ’. The ‘ stark inequalities ’ in services were responsible for huge gaps in treatment outcomes and life expectancy .
‘ The view from the system is that people are hard to reach and difficult to engage ,’ she said . ‘ We talk about frequent flyers , but not as a reward – it ’ s a derogatory statement . The system sees these people as difficult and expensive .’
‘ Treating substance issues is now a normal part of general practice ... But back then it wasn ’ t , and I think through the network and the conference and SMMGP we ’ ve mainstreamed these ideas .'
DR CHRIS FORD
In many cases people had very low expectations of their own health , particularly where they saw people around them who were worse off than they were . The
project heard views such as ‘ we ’ re doing ok because we ’ re still alive , so many [ people we know ] aren ’ t ’. When asked why they didn ’ t go to the GP sooner , another answered , ‘ because everyone hates us and we know it ’. Someone else commented that ‘ the experience of being turned away by the receptionist felt like being back in prison ’. There was a common feeling that health services were too difficult to access and engage with , and didn ’ t care about them .
‘ Shared care is one of the biggest tools in our toolbox for reducing inequalities ,’ said Wareham . ‘ Don ’ t be afraid of complexity ,’ she urged GPs . ‘ This is where you could be having the biggest impact . Let people set their own priorities and listen to the patient – they know their own health . We know when something is abnormal for us .’
There needed to be a shift in perception , to seeing them as a person instead of a problem . The very necessary conversations about trauma had to move away from ‘ what is the matter with you ?’ to ‘ what happened to you ?’ and GPs needed to appreciate that their priorities might differ , ‘ so don ’ t push everything at them at once ’. They might not be ready for smoking cessation right now , for example .
Building a trusting relationship would give many more opportunities for the patient to come back and a much greater chance of making vital progress . DDN
Julian Claxton / Alamy
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