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Breaking the specialist – primary care services barrier in treating heroin addicts: GPs’ satisfaction with local drug services and readiness to prescribe opiate substitutes.
Sanju George 1, Sylvie Boulay2, Mary Ryan3, Ann Mcdermott4, Paul Wallace5, Shyam Saikia6, Tim Farley7, Chris Clarke8
1Consultant and senior research fellow in Addiction Psychiatry, The Bridge Substance Misuse Service, Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT), 2Team manager at The Bridge Substance Misuse Service (BSMHFT), 3,4Substance Misuse Nurses, The Bridge, 5,6GPs in shared care, 7Service Manager, The Bridge, 8Solihull Drug Action Team commissioner
Shared Care is the joint working of addiction specialists and general practitioners (GPs) in treating patients with drug misuse problems. But there is still considerable reluctance among GPs to prescribe opioid substitute medication to their heroin – dependent patients. We carried out a survey of all (N=133) GPs in Solihull to explore their readiness to take part in Shared Care and to identify any barriers to prescribing. Key findings included a high awareness (98%) of drug services in Solihull, a very good rating of the service (85% of GPs scored 5 or above, on a scale of 1 to 10) and low willingness to prescribe (55% of GPs were not willing to prescribe opioid substitutes and 15% were unsure). Reasons given for reluctance to prescribe were lack of training, and inadequate resources and support. In the context of our survey findings, we also discuss various actions we have taken to encourage more GPs to sign up to the Shared Care scheme.
Shared care is the joint working of addiction specialists and general practitioners (GPs) in treating patients with drug misuse problems. Its main objective is for stable heroin users to be treated by their own GPs which provides them with an opportunity to receive a more holistic treatment – i.e. not just opiate substitute medication, but also the whole range of medical and other interventions which can be provided in a primary care setting (George et al, 2007). This concept of ‘shared care’ or close, joint working between addiction specialists and GPs is heavily emphasised in various recent Government documents (DoH, 2006; DoH, 2007) and is seen as key to comprehensively addressing the treatment needs of drug users in the UK.
Solihull is a West Midlands Metropolitan Borough Council of around 200,000 residents. In Solihull, there is one long established statutory (NHS) specialist treatment service for Class A drug users – The Bridge – that offers opioid - substitute prescribing for heroin addicts. The Bridge works closely with ‘Welcome’, a non-statutory drug agency that offers a wide range of psychological and social interventions. Historically in Solihull, as in other regions in the UK, GPs have been reluctant to ‘sign up’ to the shared care scheme but would rather their drug using patients receive treatment from The Bridge, even when they become stable enough to be managed in primary care. As our best efforts (at The Bridge) failed to implement a ‘pure’ shared care model (wherein all GPs prescribe opiate substitutes for their own heroin using patients, with support and advice from The Bridge), we set up an ‘intermediate’ model, i.e. two experienced GPs (and two senior nurses from The Bridge) provide a shared care service for all other GPs’ patients. This model is described in details elsewhere (George et al, 2007). Currently, although there are 90 heroin users on substitute medication – i.e. methadone or buprenorphine, in our intermediate shared care service, only 20 patients are in ‘pure’ shared care and there are only 10 GPs in Solihull (out of a total of 133 GPs) who are prescribing opiate substitutes for their own patients. Given the above picture, we set out to conduct a survey of all GPs in Solihull, with a view towards finding out how we could further expand the shared care scheme.
The two specific objectives of our survey were: first, to find out Solihull GPs’ awareness of and overall satisfaction with our drug service, and second, to determine GPs’ readiness to take part in ‘shared care’ (and prescribe opiate substitute medication for their own heroin using patients) and to identify any barriers to prescribing.
In January 2008, we conducted a postal questionnaire survey of all GPs (N=133) in Solihull. The questionnaire consisted of four questions that had to be answered in a yes/no format (Q1. Are you aware of services for drug users in Solihull?; Q2. Have you ever had contact with drug services in Solihull?; Q3. Would you consider prescribing methadone or subutex for your heroin using patients? and Q4. Would you like more information about the way shared care works in Solihull?). Another question asked GPs for a rating of drug services from 0 (very poor) to 10 (excellent) and one question asked GPs to rank (in order of importance) from 1 to 4 the most important factors they expect from the local drug service. Options provided included ease of referral, feedback to GP about the patient, short waiting time, and qualified and experienced staff. There were also two open-ended questions: one asked what factors would make it easier to take on opioid substitute prescribing and the other asked for any other comments on GPs’ expectations of drug services in Solihull.
Questionnaires were sent to GPs with a covering letter and a self – addressed envelope for return to The Bridge. Non-responders were sent reminders after four weeks. Responses were tabulated (numbers and percentages) and are presented as text and graphs in the next section.
Ninety-four of the 133 GPs returned completed questionnaires, giving a very good (for postal questionnaire surveys) response rate of 71%. Please see the figure below (Figure I) for a geographical representation of GPs who are signed up to shared care and those who are not. In presenting the results, where appropriate, we have categorised them as follows:
• GPs whose practice had signed up to shared care vs. not signed up
• GPs willing to prescribe opiate substitutes vs. GPs unwilling
• GPs in North Solihull (more deprived) vs. South Solihull.
As is evident from the bar chart (Graph I) above, almost every GP who responded was aware of drug services in Solihull and most (78%) had contact with the services.
GPs’ ratings of the Solihull drug service
64 GPs out of the 75 who responded to this question (85%) rated the service at 5 or above (0 = very poor and 10 = excellent). In addition, 90% of GPs in practices signed up to shared care rated the service at 5 or above compared to 82% for GPs in practices not signed up. There was little difference between GPs in the North (88% rated the service at 5 and above) and those in the South (86%). Perhaps not surprisingly, GPs willing to prescribe rated the service higher (92%) than those not willing (77%).
GPs’ expectations from the local drug service
GPs were asked to rate the following from 1 to 4 (with 1 being the most important): short waiting time, ease of referral, qualified experienced staff and feedback to GP about the patient. A large number of respondents indicated that several or all of these were rated equally so there is an element of double counting in our results: Ease of referral was rated as the most important factor by 49% of GPs, closely followed by feedback about your patient (44%), qualified experienced staff (37%) and short waiting time (27%).
GPs’ willingness to prescribe opiate substitute medication
As shown in Figure 2, overall 30% of GPs were willing to prescribe substitutes, 55% were not willing to prescribe and 15% were unsure. Not surprisingly a greater proportion of GPs in practices signed up to shared care were willing to prescribe (55%) compared to GPs in practices not signed up (11%). The high proportion of GPs not willing to prescribe is concerning: 30% of GPs signed up and 74% of those not signed up. Percentages were similar for GPs in the North and in the South, so that location does not appear particularly relevant. Interestingly, the percentage of GPs who said they were unsure was the same for GPs whose practice was signed up and GPs whose practice was not (15%). Our results show a high reluctance to take on prescribing in Solihull even for GPs whose colleagues are involved in the care of drug using patients.
Factors which would make it easier for GPs to take on prescribing
As this was posed as an open - ended question, it made the analysis of responses difficult. However, it would appear that in the case of GPs whose practice is signed up to shared care, the most important factors (in order of the number of times it was reported by GPs) were: support from drug service, resources, time and training. In the case of GPs whose practice was not signed up, time and training were mentioned most, followed by agreement of partners and support from the drug service.
Many GPs made useful suggestions but for reasons of brevity, we provide here only a sample of their comments.
• ‘The practice participates in the shared care scheme already. It has been enjoyable. I feel well supported’.
• ‘I have found the advice I get from the service to be very valuable. The short waiting time is really helpful’.
• ‘Generally very satisfied with the service’.
• ‘Most of my contact has been for patients suffering from cocaine use, I found it very helpful’.
• ‘You give an excellent service’.
• ‘Continue your services for this ever increasing, challenging and extremely demanding work in North Solihull’.
• ‘My lack of experience in the field is a major constraint. It would be useful to have some training’.
• ‘Best left to experts who can follow up properly.’
• ‘Not keen on taking on the implications for the Practice: anxious I would be left holding the baby.’
• ‘We have a small practice and had bad experiences in the past with methadone using patients’.
• ‘Not interested in taking on work’.
Interpretation and implications
The results of this survey should be interpreted with caution in view of the response rate. Although 71% response rate for postal questionnaire surveys is generally considered to be good, we do not know the views/attitudes of the remaining 29% of GPs who failed to take part in the survey. However, having looked at the non-responding GPs, there does not seem to be any systematic bias between non-responders and responders.
Key findings included a high awareness (98%) of drug services in Solihull, a very good rating of the service (85% of GPs scored 5 or above, on a scale of 1 to 10) and low willingness to prescribe (55% of GPs were not willing to prescribe opiate substitutes and 15% were unsure). There seemed to be little difference between GPs in the North of the Borough and the South. The only noticeable difference between GPs who indicated they were willing to prescribe and those who were not was in their rating of the service offered (understandably GPs willing to prescribe rated services much higher that those who were not willing). Survey respondents also highlighted various factors that would make it easier for them to take on treatment of heroin using patients.
A particularly concerning finding was the number of GPs unwilling to prescribe opiate substitutes - 55%, and 15% were unsure. Or in other words, only 1 in 3 GPs were willing to treat heroin addicts in primary care. This finding is very similar to previous studies. Kmietowicz (2002) in a survey of 1500 GPs noted that 70% of GPs felt opiate users could not be managed in primary care. Such reluctance among GPs to prescribe for heroin users has also been reported in other studies (McGillion et al 2000; Eaton, 2004). McKeown et al (2003) in a qualitative study of GPs’ attitudes to drug misusers, looked into reasons for GPs’ reluctance to treat heroin addiction in primary care. Although they concluded that ‘GPs are becoming more confident and comfortable with drug misusers and more positive towards methadone and methadone maintenance treatment but they still feel they lack the necessary knowledge and skills’. Yet again, our survey too identified very similar factors that might make it easier for GPs to take on prescribing: resources (financial incentives, time and support from drug service) and further training. It is reassuring to note that the barriers reported by GPs (more time, more training and more support) can be overcome with adequate resource allocation. Only very few GPs held strong views against treatment of heroin addicts in primary care, and so we conclude that with appropriate and adequate support and training, more GPs can be encouraged to participate in shared care.
The high awareness of local drug services is very reassuring. We were pleased with the good rating of our services and we took the opportunity of making contact with any practices where satisfaction levels appeared low. Our results confirmed our experience on the ground that the majority of GPs are reluctant to prescribe substitutes for their patients. Our findings confirm the very wide range of reasons why this is the case. Although it is clear that more resources, time and training are required to convince more GPs to prescribe, our findings show the complexity of the factors which influence GPs’decisions whether or not to prescribe. Our research would seem to suggest that there is no single solution and that a whole range of support packages and incentives needs to be provided.
Translating survey findings into practice
Surveys become mere theoretical exercises if their findings are not ‘followed up’ and acted upon (and implemented where feasible) in practice. Hence, we have over the past few months taken the following measures in our ongoing attempts to encourage more GPs to participate in shared care.
? Following the survey, two shared care nurses (based at The Bridge) made contact with all GPs who indicated they were willing to prescribe but who were not signed up, GPs who requested more information and those GPs who expressed any dissatisfaction with our drug service. Such face - to - face discussions have helped clarify various misconceptions GPs had about shared care and as a result three more GP practices have signed up to shared care.
? A brief summary of the survey findings, along with an explanation of Solihull’s shared care scheme and referral criteria has been sent to all GPs in Solihull. As a result, one GP practice not signed up to shared care has indicated their interest in joining the scheme. It is hoped that this will help clarify how the shared care scheme works and reassure GPs of the support provided.
? In conjunction with two GPs already participating in the shared care scheme, our shared care team and Dr George will be presenting the survey findings at a GP protected learning event on 23rd October 2008.
? Publishing this paper in a journal (on line access, free of charge) widely ready by GPs is yet another means of reaching the message of shared care scheme across to more GPs.
? Of course, in the current climate of drug treatment provision in the NHS, any extra resources will need the approval of senior commissioners and policy makers. As local evidence base (our survey findings) clearly demonstrated a need for more resources, training and support to GPs, if they are to treat heroin addicts in primary care, we (The Bridge team) presented the survey findings to our Drugs Delivery Group on 25th June 2008. We have also discussed the survey key implications and potential future service re-design and resource allocation with the Solihull Drug Action Team and Joint Commissioning Group. It is hoped that our findings will inform local policymaking and service provision in the future.
It is reassuring to have proof of the very high awareness GPs have of drug services and the high level of contact they have had. We recognise the importance of ease of referral for GPs and we are putting in place all possible measures to make the referral pathway as quick and easy as possible.
However, our survey also highlights the considerable reluctance of GPs to take on prescribing of opiate substitutes: although our respondents were interested enough to complete a questionnaire about shared care, the majority (55%) were not willing to prescribe. Most worryingly, 30% of GPs in practices that are signed up to shared care are nevertheless not willing to prescribe even though at least one of their colleagues is doing so. Some of the factors mentioned by GPs as being crucial are within our control (good support from the specialist service) but we are aware of the high importance of factors external to the drug services: time, resources and training, which fall within the remit of policy makers and commissioners.
We are confident that our action plan will continue to achieve increases in the number of patients treated in shared care in Solihull. We also hope our findings will inform any future policymaking and service provision. We will persevere in our attempts to drive the treatment of substance misusers in primary care agenda forward.
1. George et al (2008). Shared care scheme for drug users – A shared baby: two GPs and one addiction consultant grow their own ‘shared care scheme’ for drug using patients’. GP Online.
2. Department of Health (July 2006), Models of Care for the treatment of adult drug misusers: update 2006, National Treatment Agency for Substance Misuse.
3. Department of Health (2007), Drug misuse and dependence, UK guidelines on clinical management, London.
4. Kmietowicz Z. (2002). GPs asked to do more for drug misusers. British Medical Journal, 324:501.
5. Eaton L. (2004). Numbers starting treatment for drug misuse increase by 20% over two years. British Medical Journal; 329:1066.
6. McGillion J et al. (2000). GPs’ attitudes towards the treatment of drug misusers. British Journal of General Practice; 50:385-386.
7. McKeown A et al. (2003). A qualitative study of GPs’ attitudes to drug misusers and drug misuse services in primary care. Family Practice, 20:120-125.
We thank all GPs who participated in the survey and our administrative staff at The Bridge (Julia Kearney, Nicola Hands and Paula Ferris)
Copyrigth Priory Lodge Education Limited 2008
First Published October 2008