Our local 'shared Care' org. is trying to let go of some of the stable pts receiving scripts from the shared care Dr. These patients are from surgeries which have opted out of the shared care LES and are not doing any opioid prescribing for drug addicts. Their proposal is that the practices that do prescribe take on these patients purely for prescribing purposes. Payment is £450 per year per patient. Our biggest fear is that these patients, will after a few months of having to see their GP for non drug related problems and seeing us for their methadone script, figure out it's much better to register with us for everything.

Obviously one of the points of withdrawing from prescribing for those practices that have opted out is to discourage this type of patient from registering with them. We are worried about the workload implications.

Anyone come across this or aware of any way to stop an en-masse patient migration?

Peter,
A similar thing happened with us, when we started prescribing, I work at a GP practice, we found everyone told there friends. We are still awaiting negotiations re us getting LES payments, hopefully this is imminent. Patients found ot they got scripts quicker from us and voted with there feet. As we don't have an LES yet, we just took the patients.
I suppose if you want to stop en-masse migration cap your service to a set number to see how things work out and increase as things progress.

Myself and a GP run a prescribing clinic for clients who don't have a GP who will prescribe for them. We have been running this for about 9 months now and it has predictably become very busy. We register them as referred patients for the script only. The idea is that when stable they return to their GP if possible, but that often doesn't happen.

Hello Peter. It is difficult from your description to be sure what your role is within what type of service. If you are a GP in a practice providing shared care for users in an area where not all practices are involved in shared care then I can identify with your worries. We had the same problem. Could you possibly clarify the situation?

Hi Peter,
'Swamping' is one of the many urban myths attaching to the treatment of problematic drug use.

In Wolverhampton, we were, and still are, determined that non-prescribing or non-Shared Care GPs could not, indeed, should not, offload their problematic drug users.
And this approach has worked, to everybody's satisfaction and benefit.

The Shared Care GPs are willing, and able, to take over the care of increasing numbers of more 'complex' patients--much of the so called complexity is better treated in Primary Care and the workload implications are close to negligible.

Go for it, with all the Primary Care strengths of rapid risk assessment, intuitive harm reduction, and the rest.

We [the gang of four] did and have no regrets.
Nor do the patients [or their GPs].

George

I'm not sure that we are 'Swamped' however, we do have a lot of substance misuse patients.
I suppose it could well be the same as taking asthmatic patients on a practice list.
Whatever condition the patients have there needs to be time to see and treat them.

Peter I am also having trouble understanding this one. Tell me if I've got this right - your shared care service which provides for your own and other non-shared care GPs' patiients is becoming saturated, so you propose to pay the GPs £450 to write scripts for them, but you imply that the patients will still be coming to you - is this for keyworking? Are these GPs really doing £450 worth of work if they are only writing scripts?
If I have got this right, I feel it is anomalous to pay so much for what is basically script writing. Will this really save the service a significant amount of time? If patients are not getting keyworking, i would be very concerned that this proposal appears to condone the idea of prescribing without any psychosocial support - this is against the evidence on treatment effectiveness. To produce the best outcomes, you need both opiate substitution plus psychosocial inteventions (in the context of a good therapeutic relationship between client and kieyworker).

George i would also like to understand what happened to those patients who were registered wth a non SM GP - how did they get a script in the end?

Hi Susi,

In Wolverhampton 14, or so, of about 140 GPs in the city see patients in Shared Care [SC].

Most will treat only their own stable patients, while the first few SC GPs [the gang of four]will prescribe for other GPs' patients, supported by a dedicated GP Liaison Team [i.e. a team of currently 4, rising to 6 very soon-with a dedicated DIP SC worker to boot-Key Workers].
Currently 200 of about 600 people in treatment are in Shared Care, e.g. I see about 60 patients at any given time, say 10 of my own list and 50 registered with other GPs.

I,and the other SC GPs, issue scripts on dedicated SC FP10 Blue/Green pads.

It seems to work well, and maybe the fact that I haven't been swamped is a sad reflection on how the local problematic drug users perceive me!!
George

PS Re payment £350 per patient per annum, paid quarterly.
SCGPs get a £1,000 'bursary' for attending 6 training sessions per annum as well.

There were proposals to develop a two tier payment system, whereby the more experienced GPs would be paid more for caring for more complex patients, doing BBV screening and immunisation etc, but we turned it down so that the money could be used to pay 'bursaries' to each GP in a Group Practice involved in SC, rather than the Group Practices only getting one bursary between all the GPs even if several were involved in SC.

Thanks for explaining that - I'm much clearer now. Just a coule of Q's: Do the patients try to register with you or are they happy with the arrangement as it stands?

I'm also interested in the idea of the dedicated prescribing pad for shared care - are there advantages in this?

I think the bursary is an excellent idea - it enforces the idea with commissioners that they should be monitoring the ongoing training. May bring this up at our next SCMG!

Susi.

In Gateshead there is an LES for drug misuse. An agency called 24/7 do the 'keyworking', (ie take urines, counselling, advise GP's about scripts) but the prescribing is done by the patients own GP's. The exception has been in some practices which have refused to prescribe at all and then the prescribing has been done by a 24/7 employed Dr who works on a sessional basis. He has accumulated 80 patients on stable scripts and it is these patients 24/7 want off their hands in terms of prescribing.

Their solution is ask GP's who are prescribing to do this for other GP's patients. The pay will be £450 per year. If we assume about 10x 20 minute appointments over a year this works out at about £130 per hour of dr time. Not sure about you but we chage £150 per hour Dr time for writing medical reports.

In reality I find with my own patients the 'keyworking' stuff is done to a variable quality. Some patients are happy and engage, some see it as superfluous and a pain in the arse. I give all my methadone customers 20min appts because by the time you have written say 6 weeks of scripts and discussed script issues 10mins is up and I think one must have time to discuss the person more generally. The keyworker/prescriber split is all very well in theory but in practice such rigid distinctions are not practical.

Our concern is that of workload. Our audit on drug addicts shows they are by far the largest consumers of Dr time. Even the terminally ill house call patients take up less. Taking on more means less appoitments for other patients and hence our wariness.

I think we'll put a cap of 50 on for now and see how it goes.

Susi the way I read Peters post was that his practice was one of the ones being paid £450 per patient for treating other practices patients. His concern was, I think, that those patients from other practices would decide it was much easier if they just reregistered with his. This would seem to make sense. However I would thought putting a limit on the number of people they are able to treat ought to solve it. In some ways, though, this process is more likely if the practice wasn't offering this service to other practices as the patients would haveto reregister to get treated by them.

sorry Peter I was writing this reply as you were posting yours so was written without reference to thepost above it.

Yes I see that I completely misread this now! Must be time I was going.....

However, i can't let this one go without strongly suggesting that you hold out for less money and more keyworking Peter. And it also sounds like you need better keyworking, which is obviously an issue for 24/7, to sort out. With extra training I have seen big changes in keyworkers I've known. It is quite possible 24/7 would like to improve the training but commissioner won't pay, in which case it looks to me like you are in a position of power to move things along in the right directiion by refusing to let them go in the wrong one.

You've probably worked this out already, but I make it 50 patients x 10 appts per year = 500 appts per year = just under 10x20 min appts per week, which is two surgeries a week out of your practice! Those figures alone should make your commissioner and your PCT sit up I would have thought

Hi Susi-generally speaking patients hardly ever ask to register with me.
On principle, we felt from the outset that non Shared Care GPs should not be able to wash their hands of their problematic drug users-the SC GPs would prescribe etc for the drug use, but the patients' own GPs would remain responsible for the rest of the patients' healthcare.

The dedicated Blue/Green pads are I think [being weak on technical matters] more for audit/accounting/costing purposes than anything else, as the prescribing costs would have very little impact on my, or any other of the SC GPs' overall prescribing costs.

Agree entirely about the bursary.

All in all it's a win-win situation for everybody, but I am always conscious that it is a delicate ecology that can easily be damaged, if not derailed at any time.

A benign indifference on the part of the PCT and frequent [4-6 weekly]meetings of the SCMG [which is mainly comprised of 'the workers'--we decide what to do and let the PCT know of our decisions]are relevant and helpful considerations as well.

George

Thanks George, whilst we're on subject of people in new roles (on another thread) congratulations to you on your getting the RCGP part 1 clinical lead post - hope it goes brilliantly

[QUOTE] so you propose to pay the GPs £450 to write scripts for them, but you imply that the patients will still be coming to you - is this for keyworking? Are these GPs really doing £450 worth of work if they are only writing scripts?
If I have got this right, I feel it is anomalous to pay so much for what is basically script writing. QUOTE]

well i go to a private doctor and they charge seventy five pounds for a two week script,so 450 a year is not much really

Hi Nick30,
Is the local Brighton NHS service not offering what is needed?

I don't know anything about Brighton, except it has a pebble beach, and a very high drug related death rate. Would it be possible for a Brighton person to get what they needed within the NHS, and spend that £1800 a year on a couple of holidays in the sun, or large amounts of fresh fruit and vegetables?

call me old-fashioned but for me the advantage of general practice care is that the person receives all health care needs, including harm reduction, prescribing vaccinations, sex etc etc., from their GP - I know we can't get all GPs to prescribe but if you take away the prescribing from them doesn't this mean that they don't these patients get their health care from them either? Big fan of the Brum system that uses GPSIs to support GPs to work with drug users rather than take over the prescribing. In our area too I don't prescribe for anyone who isn't registered and happily manage 140 people on a list size of 14,000

Agree Brum system sounds v interesting
Would like to know more please!

the keyworkers spread the word here with the clients that numbers have been capped at certain surgeries or that the Gp's wont take on new patients who havent been with that GP for atleast 6 months, seems to be working. the client grapevine is a great thing.
on another point we have a shared care system in Central Scotland, pay the GP's £350 per patient per year by invoice. i have a GP who wishes it to be superannuated, does anyone else have a system like this? the GP's are not employees but charge me a fee to prescribe for drug using clients. any info on how vereyone is pad woudl be great, GP Prescribing isnt part of enhanced service with NHS FV.