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‘Patients have
stopped attending’
Dr Peter Exley witnessed the
dismantling of
responsive healthcare
I was a GP with a special interest (GPwSI) in
substance misuse for around ten years, providing a
clinic from my surgery to local and neighbouring
practices. When substance misuse services were
transferred from the NHS to local authority control
in 2013, the service was put out to tender.
The existing service was based on GP patient
lists, but the new service was based on local
authority bound ar ies. As we were a mile from the
county border, quite a few of our patients could no
longer be treated.
We used to carry out services in a well-
equipped, centrally located, modern medical
centre. We provided nine hours a week of doctor
time spread over two days, with flexibility to see
patients outside the scheduled clinic times every
day of the week. Patients could collect scripts and
provide urine specimens from 8am to 6.30pm,
Monday to Friday, and access urgent medical
advice or discuss issues with pharmacists. Medical
reviews were set as needed, from weekly to every
six weeks.
The new service was set up in a church hall with
no medical facilities, on the far edge of the
geographical patch, and many drug users did not
attend as they couldn’t afford the bus fare. Three
hours of doctor time were provided one after noon a
week, and there was no easy access to medical
support outside this time. Staff had their own
problems to worry about – the TUPE’d drug workers
were very demoralised as some had needed to
reapply for their jobs three times in two years.
I have spoken to patients who have not received
a medical review or given a urine screen for more
than a year, and have been unable to obtain a
change to their OST for over two months. I would
frequently treat people’s medical problems when
they attended the substance misuse clinic – mainly
mental health issues, infections (especially chest),
groin abscesses, DVT etc. After the change in
service, patients stopped attending for medical
problems and turned up in A&E.
In the ten years that we ran the service, one
patient died. In the 18 months after the service
ended, before I retired, three patients died –
although one of these was probably not drug
related. GPs preferred the old system, patients
preferred the old system, drug workers preferred
the old system – but the new system is cheaper.
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‘Our patients are
casualties of
the climate’
Dr Simon Tickle has lost
trust in the system
We’ve run a GP practice with additional PMS
[personal medical services] funding for socially
excluded patients since 2001, but without any
increase since about 2005. Some of our patients
have lives that might make an ‘accidental overdose’
welcome, but a treatment environment has
developed which I feel has made that option more
attractive.
Frankly, without increased funding, we did need
the help of the new drug treatment contractors
with our 150 shared-care patients, but after two
years and eight changes in workers they decided
they needed to crack the whip. Within three months
of starting a programme to take the least stable
and more complex of our patients out of shared
care because they were unsuitable for it, we had
two heroin overdose deaths – and we’d previously
had none for years.
One was a woman with whom we had had a
warm and close relationship and had supported
through many ups and downs. She had learning
difficulties and was on a high dose of oral
methadone and ‘injecting on top’. The other was a
man whom we had managed to support
successfully, but on transfer he disengaged from
treatment as he did not want to lose his
relationship with us or be managed under their
policies, and he too was soon dead.
A supportive relationship with a known care
worker is a lifeline for such patients and they need
to be able to opt to stay with the person or agency
they trust, or at least have any transition dealt with
very sensitively. I’m not attributing blame, but I
would like to see more compassion and contrition.
My concerned email to the local service was copied
to the commissioner, but so far it has gone no
further and I feel that the episode has been quietly
kicked into the long grass.
These patients are casualties of a climate which
puts a positive spin on what has happened in
substance misuse management in recent years, but
which is in fact deeply sad and bad for many. I have
lost trust in the system – the same as many of my
patients did very early in their lives. DDN
December/January 2018 | drinkanddrugsnews | 13