Scanbites Autumn 2008 Vol 5 Issue 3

2008·1 MB·English

by  Specialist Clinical Addiction Network

POLICY SPECIAL ISSUE
bites
“Not all that
SCAN
interests the public
is in the
public interest”
Page 6
The quarterly newsletter of the Specialist Clinical Addiction Network | Autumn 2008 | Volume 5 Issue 3 | ISSN 1744-6112
Guest editors Dr Julia Sinclair and Dr Judy Myles, SCAN policy advisors
In this issue
As the NHS turns 60 Judy Myles - this page
- reviews the proposed NHS constitution
and urges all addiction specialists to
respond to the consultation process.
■The main theme of this
issue is policy: two reviews
consider the implications
for addiction services of
Lord Darzi’s recent reports.
On page 2 Kylie Reed and
Francis Keaney review the
Darzi report ‘High Quality Care for All’ and
Julia Sinclair examines the role that is
envisaged, in ‘A High Quality Workforce’,
for the clinicians of the future. Page 3. On
page 5, Colin Drummond reviews the
progress on the government’s alcohol
NHS AT 60 GETS A NEW CONSTITUTION
strategy and sends the message SSS-SOS!
Dr Judy Myles, SCAN Policy Advisor standard in considering the professional ■ Clinicians have long
conduct of doctors. struggled with the tension
THE DRAFT NHS Constitution, released There is much within this draft that would between patient
alongside Lord Darzi’s ‘Next Stage Review’, improve treatment for our patients. It proposes confidentiality and
went out for consultation on 30 June with that patients will have the right to drugs and information sharing across
comments invited by 17 October. treatments recommended by NICE, something agencies. Gwen Adshead
It is described as the product of a ‘wide that is still a ‘postcode lottery’ despite the discusses the ethical
process of consultation and research into what current requirement on PCTs to make funding dilemmas involved on page 6, and Aideen
matters for staff, patients and the public’ and available. Additionally it states ‘the NHS will O’Kane and Eilish Gilvarry consider the
has consulted with various organisations to provide a universal service for all based on matter in relation to the guidance on drugs
‘identify and test the values contained’ within. clinical need’ which will challenge the and driving. Page 15.
However, although RCGP, RC of Midwives, increasing demand for treatments to be offered
RCN and RCP are listed as involved, RCPsych, preferentially to those within the criminal ■ Three new SpRs join the SCAN team for
NTA or SCAN are not. Given the multiple justice system rather than those in greatest
the year and they introduce themselves on
health needs of patients suffering drug and clinical need. Two further principles about the
page 9; while the current census of SCAN
alcohol misuse and addiction there is a clear prioritisation of access to services for drug and
members is summarised on the back page
imperative for SCAN members to respond alcohol patients need consideration; first that
and plans for expansion discussed by Amy
within the timeframe. The Constitution will not the NHS will work across organisational
Wolstenholme on page 7.
be passed into law, but it will be a ‘declaratory boundaries in the interest of ‘patients, local
communities and the wider population’ and
A TENSION REMAINS UNADDRESSED ■ In the summer issue of SCANbites,
second that the NHS has a wider social duty.
Keron Fletcher outlined his concerns about
document’ bringing together existing legal This means that the tension that currently
the commissioning of specialist addiction
rights and including one new right concerning exists, of whether to prioritise treatment
services in an open letter to the NTA. On
patient choice. according to clinical need or to reduce criminal
page 4,
One of the questions posed in this draft is behaviour, remains unaddressed, as does the What’s special about
Annette
‘should all NHS bodies and NHS funded issue of health treatment funding, via the DATs, addiction specialists?
Dale Perrera
organisations be obliged by law to take account coming increasingly from Home Office rather A letter from Dr Keron Fletcher,Chairman of
of the NTA Addictions Faculty UK Regional Representatives of
of the NHS constitution?’ The proposal is that than NHS funding streams. theRoyal College ofPsychiatrists,totheNational
responds… Treatment Agency for Substance Misuse
the NHS Reform Bill will include such a duty The Handbook to the NHS Constitution is Dear NTA,
It was a pleasure to meet up with you at the
on NHS bodies. Therefore, it is probable that on www.dh.gov.uk/consultations; comments Addictions Faculty Residential Conference last
week. I am grateful to you for listening
carefully to some of my concerns and for
the principles contained within the final NHS can be sent to [email protected] suggesting that I put pen to paper and
forward my comments to you.
Constitution, like the ‘Orange Guidelines’ will or to SCAN where we will collate a response on
be considered by the GMC as the acceptable behalf of the membership.
www.scan.uk.net
REVIEW
THE DARZI REPORT: ITS RELEVANCE TO
DRUG AND ALCOHOL SERVICES
IN JUNE2007, Professor Sir Ara Darzi was appointed enterprise organisations; and the possibility that each client
as Parliamentary Under Secretary at the DOH.1 will carry a personal health budget.
Holder of the Paul Hamlyn Chair of Surgery at There is a focus throughout on preventive medicine,
Imperial College London, he first trod a path in and it is in this context that treatment for “tackling drug
medicine in the late 70s, when he left Iraq, his country addiction” receives its only mention, alongside the first of
of birth, to study at Trinity College, Dublin. A ‘prolific several references to “reducing alcohol harm”, each listed
academic and devoted clinician’, he was a pioneer of as one of six key goals. Each PCT will commission
keyhole surgery in London.2,3,4 “comprehensive well-being and prevention services, in REFERENCES
In his political role, he declared his clinical focus partnership with local authorities… personalised to meet
unaltered. “I am not a politician by profession. My working the specific needs of their local populations”. We are 1 “Brown unveils
life has, is and will continue to be centred on patient informed that this will be supported by the investment of new faces”, 29 Jun
care.”5His remit is to “improve the quality of patient-care, “new resources in the areas that are worst affected by 07, published on the
increase the convenience and accessibility of health services alcohol-related ill health”. Mention is afforded to an official website of
and build a new partnership with NHS staff and patients”.5 expectation that local PCTs will develop and expand alcohol the PM’s Office,
On 30 June the product of this endeavour was unveiled: brief interventions. It might be hoped that the proposed www.number10.gov.
uk/Page12225
‘High Quality Care for All’, a report composed in
CONCENTRATING ON GRAND ASPIRATIONS
consultation with 2000 clinicians across the country, sets
2 “Professor Sir Ara
Dr Kylie Reed, out the vision for the NHS over the next ten years.6 150 GP-led health centres (not to be confused with the
Darzi”, 29 June 07,
Honorary As the title enthuses, the vision for the NHS, as it London based polyclinics proposal), may provide some of
www.number10.gov.
Specialist marches into its sixtieth year, is no longer focused on the this care. These will provide additional access to primary
uk/Page12232
Registrar, and Dr increase of supply to meet demand that has characterised care services, on a walk-in basis, 365 days a year, with
Francis Keaney, the last decade; the 2008 publication calls for a honing of provision tailored locally to meet the community’s needs.
3 Desert Island Discs,
Consultant this body of health care into a product of greater quality - Darzi’s report concentrates its energy on grand BBC Radio 4; first
Addiction the ‘Next Stage’.6 Quality, in this context, Darzi defined as aspirations, the broad tenets being quality and equality; but broadcast 22 June
Psychiatrist, South “ensuring patient safety; optimising the effectiveness of it is studded with very few practical details. There is 2008.
London and healthcare outcomes; and enhancing patient experience”. perhaps sufficient mention of ‘tackling drug addiction’ and
Maudsley NHS Cleanliness, infection control, and minimising drug ‘reducing alcohol harm’ to assure us that drug, and in 4 www.imperial.
Foundation Trust. errors are examples of areas through which to ensure particular alcohol, services will benefit from the next ac.uk/medicine/
safety. Under the umbrella of optimising effectiveness, the decade’s refinements; and in the case of ‘alcohol-related people/a.darzi/
report includes expediting NICE reviews and ensuring harm’, investment of new resources in the areas worst
approved treatments are available to all who would benefit. affected is promised. Given the emphasis on preventive 5 “Personal
Patient experience, meanwhile, is given a new emphasis, medicine, we may also expect a greater involvement of Statement from
with a promise to measure patients’ own assessment of the primary care in the early management of our client groups. Professor Sir Ara
compassion, dignity and respect with which they were We now await each PCT’s five year plans, promised in Darzi”, 2 July 2007,
www.number10.gov.
treated. Healthcare providers will be legally required to Darzi’s report by Spring 2009, to learn more of how Darzi’s
uk/Page12246
publish ‘Quality Accounts’ “just as they publish financial enthusiastic vision may impact drug and alcohol services at
accounts”6. Clinical excellence awards for consultants will a local level.
6 www.dh.gov.uk
be more focused on clinical activity and quality measures. The report lays out the direction and principles for
/en/Publicationsandst
In the main, the report is concerned not with mental delivery of a couture health care system equally accessible
atistics/Publications/P
health but with the acute sector. However, whilst Darzi to everyone. On the eve of its release, The Sunday Times
ublicationsPolicyAnd
does leave a great deal to our imagination, there are four commented “Darzi’s watchwords are courage, innovation,
Guidance/DH_085825
suggested developments around which we have some and best practice”.7It could be argued that our services,
familiarity: involvement of the commercial sector in the subject already to intense scrutiny from commissioners and 7 “Profile: Ara
provision of services; resurrection of practice-based the NTA, have evolved early, ahead of the “High Quality Darzi”, The Sunday
commissioning; encouragement of NHS staff to form social Care for All” template that Darzi proposes. Times, June 29 2008.
2| Supporting specialists, promoting consensus
REVIEW ETHICS
A HIGH-QUALITY WORKFORCE? IN THE SPRING 2008 ISSUE OF SCANBITES
THE3 VIEWS PIECE CONCERNED AN
IMPLICATIONS OF THE DARZI REPORT FOR ETHICAL DILEMMA INVOLVING CLINICAL
AUDIT. HERE, DR JOHN DUNN PROVIDES
SPECIALIST ADDICTION CLINICIANS THE NATIONAL TREATMENT AGENCY'S
VIEW OF HOW THE CLINICAL SERVICE
SHOULD RESPOND TO A REQUEST FOR
Julia Sinclair SCAN policy advisor
CONFIDENTIAL AUDIT INFORMATION.
A High Quality workforce1is the accompanying policy They recognise that doctors are vitally important THENTA is strongly supportive of clinical audit,
document to the main report of Lord Darzi High Quality because of their core skills in: which is an essential tool in the armamentarium
Care for Alland aims to explain how the findings might (cid:129) Leadership of clinical governance. The NTA encourages
translate in terms of workforce planning, training and (cid:129) Dealing with complexity and managing uncertainty DATs to establish multi-agency groups to oversee
education within the NHS. (cid:129) Effective and efficient problem solving clinical governance for the whole treatment
The main report is reviewed on the page (cid:129) Working with patients to take legitimate risks and system across partnerships. This may result in
opposite. Here I examine the implications that the effectively managing risk by providing information system-wide clinical audit topics being agreed,
implementation document may have for specialist alongside professional judgement to maximise with each provider being audited on the same
addiction clinicians. patient independence and choice measures. We are aware of examples of this
The document is broad in its definition of ‘clinician’ (cid:129) Grasping situations intuitively based on a deep, from around the country. In one example, case
but is explicit in that it includes ‘all those who provide tacit understanding of their area of practice notes were photocopied and anonymised (all
clinical care for patients and the public’. It emphasises identifiers were removed), before being
the need for teams of clinicians, managers and support reviewed by an external consultant. In another
staff to work together to provide effective services. A Education and training example a peer audit project was developed
key concept running through the document is that the Much of the document concentrates on education and with substance misuse services within a
clinician in our modern NHS has three main roles; that training pathways for different professional groups. In partnership auditing each others’ case notes
of Practitioner, Partner and Leader. terms of the training for doctors, the aim is to work against set criteria.
with the Royal Colleges to develop a ‘modular
Practitioner, Partner and Leader credentialing’ system of accreditation at points through Service providers in the NHS have a duty to be
The document clearly states that the role of the clinician the training process. For addiction psychiatrists this involved in clinical governance and undertake
remains first and foremost that of a practitioner, and means that we will need to have some consensus on regular and timely clinical audits. Individual trusts
more importantly it reinforces the importance of what we see as our fundamental roles and may have local audit priorities but we would
professional judgement, creativity and innovation in responsibilities in order to accurately operationalise encourage substance misuse services to work
that role. those into core competencies that can then be closely with other substance misuse providers
However, the modern NHS clinician is also required accredited. The danger with this is that training will and their commissioners.
to contribute beyond the traditional role of skilled become more rather than less prescriptive, and that if
practitioner. The aim is also for us to be active ‘partners’ there is no clear career progression, or security of Sharing of confidential clinical information is
in the delivery of healthcare, including the stewardship identity within the speciality, less people are likely to opt governed by central guidance from the
of its resources. The authors emphasise that, where for addiction psychiatry as a specialty early on in their Department of Health. All NHS trusts must have
appropriate, we should offer leadership in one or more careers. However, initiatives such as project TASk (see a Caldicott guardian, usually a senior medical
of the fields of research, education and service delivery. page 14) may be one way forward. officer, who has the responsibility to oversee all
There is always a danger that this kind of ‘vision’ For those of us who have completed our training procedures affecting access to person-
document presents broad and bland aspirational there is also the matter of ongoing accreditation, and identifiable health data. Examination of case
statements with which few would disagree, but which the development of skills (e.g leadership, business notes would involve access to such data and,
are difficult to define or operationalise. So it was planning and health economics) that will be needed if therefore, the trust should seek guidance from
heartening that positive and clear messages came out we are to fulfil the role envisaged for us. Although the its Caldicott guardian before a decision is made
of Lord Darzi’s consultation about the features authors recognise that 60% of the staff who will deliver about allowing an external organisation to read
distinctive to medical practitioners. services in the NHS in 10 years’ time are already case notes. Although identifiers can be removed
At a time when, particularly within addiction employed and that there is a responsibility to skill us to this may not always be possible or practical.
services, the role of the specialist appears to be fulfil those roles it is less clear on how this is to be done.
marginalised it is encouraging to see in the document A High Quality Workforce1builds on Lord Darzi’s Where it is expected that clinical information will
that the public and patients at least have clear ideas of consultation and so the principal theoretical driver is, be routinely shared between organisations, for
the role of the doctor and what are their core skills (see correctly, the needs of the patient. The potential example between DIP
boxes below). difficulty remains that the financial driver for the and a NHS specialist drug
implementation remains in the hands of commissioners. treatment service, it is
NHS patients and the public expect their doctors to: This means that if we, as specialist clinicians, are to be usual practice to develop
(cid:129) Achieve accurate and timely diagnoses able to deliver the role that our patients still want us to an information sharing
(cid:129) Ensure the safety of patients fulfil, we are going to have to ensure that protocol. Such a protocol
(cid:129) Help patients navigate through the healthcare commissioners are aware of this document and of their would be vetted by the
pathway responsibility to commission the high quality services it Caldicott guardian before
(cid:129) Contribute appropriately as a leader of or partner in demands. implementation and An ethical dilemma
the clinical team clients would be asked to involving clinical audit
(cid:129) Contribute to healthcare research, development REFERENCE sign a consent form at We run a community substance
misuse team in a town. The local
and innovation 1 A High Quality Workforce - NHS next stage review. DAT recently demanded to audit
(cid:129) Train future generations of healthcare professionals DoH (2008). www.dh.gov.uk/publications (cid:2) Page 4, column 3 our clinical notes to find out how
we would react to this audit
SCANbites, autumn 2008 | 3
LETTER
What’s special about Some practice falls short of this aspiration, CLINICAL AUDIT: A RESPONSE FROM THE NTA
and we all need to guard against any
addiction specialists? “dumbing down” in specialist skills. It is
not in our clients’ interests to sacrifice
quality to a false economy of services with
A letter from Dr Keron Fletcher,Chairman of
Addictions Faculty UK Regional Representatives of poor clinical governance and low
theRoyal College ofPsychiatrists,totheNational competence.
Treatment Agency for Substance Misuse There is also variability in the
DIt ewaars N aT pAle,asure to meet up with you at the cwoomrkpse hteanrdce t oo fp croommomties scioonmeprse.t eTnhte NTA (cid:2) previous page
Addictions Faculty Residential Conference last
week. I am grateful to you for listening commissioning, through the provision of the point of entry into the treatment system.
carefully to some of my concerns and for guidance, national training with Oxford Even with the client’s consent, the form would
suggesting that I put pen to paper and
forward my comments to you. Brookes University, delivery assurance of only allow the sharing of information relevant to
local treatment plans, and the the client’s care in respect of that organisation or
NTA/Healthcare Commission improvement the person named on the consent form. It would
reviews. We should also acknowledge not be appropriate to use this mechanism to
A RESPONSE FROM THE NTA
variability in the competence of all enable external agencies to view case notes for
professional groups - including addiction the purposes of clinical audit. In rare
In the Summer 2008 issue of SCANbites we published a psychiatrists - and accept that in some circumstances an inspection by the Healthcare
letter from Dr Keron Fletcher of the Royal College of instances criticism of colleagues may be Commission could be triggered by serious ethical
Psychiatrists to the NTA on growing concerns about justified as long as it leads to improvements or clinical concerns in which case clients’ case
commissioning of specialist addiction services. Here in practice. notes would be inspected by an external agency,
Annette Dale Perera, Director of Quality of the NTA, However, I do not agree that targets albeit a statutory body.
provides a response. and re-tendering are all bad. Without the
accountability of targets, drug treatment The interface between research and audit and
would not have received additional the role of the Local Research Ethics Committees
Dear Keron, resources or continued priority status. Re- (LREC) is another area that should be addressed.
The NTA does recognise the unique and tendering is also appropriate in many There was a time when clinicians were given a
valuable contribution of addiction circumstances, for example, where a local relatively free hand in undertaking clinical audits
psychiatrists. The success we have all system needs re-engineering to better meet without having to pass them by LREC.
achieved in doubling the numbers in drug local needs, or when efforts to improve a Increasingly LRECs have taken clinical audit under
treatment has been matched by a poorly performing service have failed. It is their wing. The boundary between clinical audit
massive expansion in addiction also sometimes required by European and and research is increasingly blurred - some audits
psychiatrists, currently 453 in the NHS in local authority tendering directives, though use sophisticated methodologies, produce results
England, according to SCAN. This I agree that all cases should be handled of general interest and there may be an a priori
represents a massive endorsement of the with due care. If providers do have intention to publish the results in a report or peer
contribution that addiction psychiatrists concerns about tendering process or reviewed journal. In these circumstances it would
make to drug treatment, which was service specifications, they can contact the be good practice to submit proposals for clinical
explicitly recognised in Models of Care for NTA. audit to the LREC so that the ethical implications
Drug Misusers.1 Finally, you make some helpful can be scrutinised by a panel of experts.
Having said that, I do think there is a suggestions as to how the NTA can help,
lack of understanding about the and we would welcome the opportunity to Separate from clinical audit is the question of
contributions of different doctors discuss this with you, SCAN and the performance management and it may be that
working in addiction. More could be College. The NTA is working with key the two issues have become confused in the
done to promote awareness among stakeholders to develop new example. Commissioners need to monitor the
commissioners and providers of the commissioning guidance, and you performance of local service providers, usually
potential contribution of addiction represent the College on that group. In against a mixture of nationally and locally agreed
psychiatry. The NTA sees the College and addition the NTA will look at how it can performance indicators. Performance
SCAN as playing key roles in this. promote the role of the profession in its management should be explicit. Service level
Historically, some areas have not had workstreams on enhancing the workforce agreements and contracts should detail the type
addiction psychiatrists, and unfortunately and promoting better clinical governance. of indicators against which service delivery will be
so far our data has not allowed us to say We also hope to continue and strengthen measured and judged. Poor performance needs
whether this made a difference to the joint work between the college to be identified and addressed through regular
Annette Dale- treatment outcomes, although the regional representatives and the NTA contract monitoring meetings between
Perera, forthcoming outcome-focused data of regional teams that has been very commissioners and providers. But performance
Director of TOP may change this. beneficial to both sides. management and clinical audit are distinct
Quality, NTA You raise increasing reports of entities.
commissioning hostility to addiction Yours sincerely,
psychiatrists. Other providers have made (The NTA has published a guidance document on
similar complaints, so this may not be Annette Dale-Perera, Director of Quality clinical governance, which is currently being
particular to addiction psychiatry. There National Treatment Agency for Substance revised following consultation and which is due
will always be some tension between Misuse for publication in September 2008.)
commissioners and providers, but we
need them to work together in mature REFERENCE John Dunn
relationships to design and operate local 1 NTA (2006) ‘Models of Care for Drug Misusers’ Consultant Psychiatrist and NTA Clinical Team
treatment systems that meet client needs. London Leader
4| Supporting specialists, promoting consensus
Comment
SSS - SoS...
A consultation on the shape of the emerging alcohol strategy
in England has been launched by the Department of Health.
Prof. Colin Drummond, SCAN lead, explains why we should
engage with this exercise.
LOOKING BACKto 2004 it is clear that the fruition of many of the initiatives envisaged drivers of alcohol related harm and the need
Government did not feel there was a strong by SSS in the form of a series of chunky for tougher strategies to tackle price,
enough case to be made for the tougher reports which went out for public availability, promotion and sale of alcohol.
alcohol strategy measures recommended by consultation in July. The ministerial foreword Although the shift in Government thinking
their health advisers. Nor did it feel that there states that “this consultation is aimed at on whole population measures is something
was enough public concern about alcohol or gathering views about how far Government of a minor triumph for reason over belief,
public support to introduce whole population action should go and what is the legitimate the picture for early intervention and
measures to tackle alcohol misuse. Hence we and necessary balance between individual treatment appears more stuck. The latest
ended up with an edentulous Alcohol Harm responsibility, consumer choice and restricting idea is to target the PCT areas in the country
Reduction Strategy for England, and soon after, harmful retailing practices… There is no with the highest level of alcohol related
relaxation of the alcohol licensing laws. dispute that current levels of harm need to be admissions to provide additional funding
tackled.” Much of the impetus behind this and support to develop more treatment and
The problem with alcohol was largely recast as appears to be revised estimates of the scale early intervention services. While this is a
a criminal justice issue, predominantly affecting of the problem, including increased costs to start, the national alcohol needs assessment
young people. Many of the more controversial the NHS through increasing hospital (ANARP) showed that even in the better
or costly measures were either deferred for admissions due to alcohol: an increase of served areas of the country, we still have a
further research or piloting, or ruled out of the 80,000 admissions per year. relatively low level of treatment access by
strategy altogether. You could imagine the international standards.
sound of corks popping in the boardrooms of Importantly there is recognition that the
the alcohol industry when AHRSE was increase in hospital admissions is directly Fortunately this is not the end of the story.
launched! linked to the increasing affordability of The National Audit Office is due to publish a
alcohol, as well as a shift towards higher report on the value for money of current
Since then, not surprisingly perhaps, the NHS spending on alcohol related harm. One
FOR THE FIRST TIME IN THIS SAGA,
statistics on alcohol related harm have hopes that this will emphasise the
A WINDOW OF OPPORTUNITY
continued their upward trend, and public importance of local investment in early
concern about alcohol has increased. Even strength drinks. The consultation paper also intervention and treatment services as a
sectors of the press that were previously critical notes that 76% of the alcohol consumed in means of reducing alcohol related harm.
of “nanny state” approaches to alcohol began the UK is imbibed by the 23% of the Then there is a raft of NICE alcohol
to change their position in favour of firmer population drinking above the recommended guidelines under development. These will
action. levels. cover public health strategies, screening and
brief interventions, and treatment of alcohol
Three years after the AHRSE was launched, A review of alcohol pricing and promotion dependence. Although they are not due to
along came Safe, Sensible, Social. Where conducted for the Department of Health by report until 2010 they are likely to have a
AHRSE was lacking in teeth, SSS could best be Sheffield University has shown that price has crucial impact on the shape of alcohol
described as flaccid. As reported previously in the greatest impact on young people and treatment services. SCAN is a stakeholder in
SCANbites, SSS again deferred many of the heavier drinkers, and evidence of a link these consultations and will continue to
key decisions about price and promotion of between advertising and drinking in young emphasise the importance of alcohol
alcohol, and treatment for people with more people. Further, a report by KPMG treatment as part of the full range of
serious alcohol problems, in favour of tougher commissioned for SSS showed continuing measures needed to help people with
enforcement, more research, public poor industry practice in relation to promotion alcohol problems.
information campaigns, and further of cheap alcohol and bulk purchasing, and
consultation. It appeared the Government limited adherence to voluntary social So if you have not done so already, I would
recognised that much more needed to be responsibility codes. As a result the urge you to take part in the Department of
done to tackle the alcohol problem, but SSS Government is considering statutory Health consultation on SSS which closes on
bought some more time. Only a small amount enforcement of industry standards. Also there 14 October. There is for the first time in this
of new money was set aside for early is the issue of public health considerations saga a window of opportunity to influence
interventions and treatment, some of which becoming a mandatory part of licensing Government policy in favour of introducing
did not even reach its intended destination: decisions, which was notably absent from the effective public health alcohol strategies.
the result of devolved decision making on local 2003 Licensing Act. SSS is sending you a message: SSS-SOS!
health spending.
So four years on from AHRSE, there is now (cid:2)Details of consultation: www.dh.gov.uk/en/
So now, a further year on, we have the some recognition by the Government of the Consultations/Liveconsultations/DH_086412
SCANbites, autumn 2008 | 5
ETHICS
Sharing and withholding information
Gwen Adshead considers ethics and anxieties
ETHICS ISthe discourse of ‘ought’ and social aggression). Respect for that them to take part in risk assessment,
‘should’. In clinical practice there are vulnerability generates the principle we may feel compelled to disclose the
many occasions when we can take a of confidentiality, and the ethical results to others with or without their
course of action, but are unsure duty not to disclose without consent. consent. Second, the Department of
whether we should. Ethical dilemmas Note that there is no breach of Health policy oscillates between a
are recognisable by (a) the tension confidentiality when the patient is rigidly protective approach to patient
between two value sets or principles, informed and has consented. information and an anxiously open
or two sets of anticipated It is ironic that clinicians usually stance, when it comes to risk
consequences, and (b) the anxiety only have a problem with management.
this tension causes. confidentiality when they want to On the one hand, increasingly
When, how and if to share breach it! Furthermore, clinicians also elaborate and complicated strategies
patients’ personal information with find that they want to do this either are required to prevent third parties
third parties is currently a particular (a) without informing the patient, (including clinicians not directly
source of ethical tension in mental which is a type of deceit or (b) in the involved in a patient’s care) from
health work. External inquiries into face of the patient’s flat refusal, getting access to patient data. Patient
clinical tragedies have repeatedly which is disrespectful and may be information is to be treated as
Dr Gwen suggested that failures in private property, over which the
ELABORATE STRATEGIES REQUIRED
Adshead communication contribute to patient has complete rights,
Consultant disasters. At the same time, clinicians experienced as aggressive. It is supported by article 8 of the Human
forensic recognise the need to respect professionally accepted that the duty Rights Act.
psychiatrist. patients’ privacy, and are uneasily of non-disclosure is not the same as a On the other, the moment that
Broadmoor aware that patients may not realise duty of absolute secrecy. Clinicians anyone perceives the patient’s case to
hospital, West how much information is shared with usually justify breaching involve some issue of risk, the patient
London Mental others. confidentiality in the name of risk can kiss goodbye to any claims to
Health Trust The ethical arguments for not reduction or harm prevention; which privacy. Clinician anxiety about risk
sharing patient information without is a meaningful justification for (not even the risk itself) appears to be
the patient’s consent are based on information disclosure. This is enough to justify disclosing anything
the principle of respect for patient codified in the GMC guidance on about the patient in the name of risk.
autonomy. Our autonomy is based on confidentiality, and the NHS code of Section 30 (Annex B) of the NHS
our personal identity, and our practice on confidentiality. code of confidentiality for all staff1
personal information is part of that There are a number of problems states that clinicians are permitted to
identity. with the current situation. First, it is breach confidentiality in the
Sharing that information makes not at all clear that patients ‘detection, investigation and
us vulnerable to gossip (a form of understand that, when we invite punishment of violent crime’ (my
6| Supporting specialists, promoting consensus
SCAN
SCAN
EXPANDING SCAN
italics). It is not clear what the time
scale for the anticipated violence
could be, or should be. Putting expansion into context… constituency as the Royal College teams – considering the important
Addiction specialists face the issue of Psychiatrists. Early on we roles of clinical psychologists and
of information disclosure acutely MOST SCAN members, particularly negotiated the status of affiliate specialist nurses, and perhaps the
because of the link between substance the “originals”, will be familiar membership for our colleagues in more specialised end of specialist
misuse and risk. with how SCAN came into being, Scotland, Wales and Northern GPs. We recently held an informal
It is well known that substance and why. Ireland as well as the Republic of meeting with representatives
misuse substantially increases the risk Ireland. We established from the Addiction Faculty of the
of violent offending, such that any Commissioned in 2003 by the agreements with the appropriate British Psychological Society,
patient with a substance misuse Department of Health in England UK devolved administrations where areas of common ground
history and a history of violence and (DH), the principal aim of SCAN beyond the English border to and potential closer working have
an Axis 1 disorder is, actuarially at was “to provide support and ensure that their specialists were been identified.
least, at much greater risk of violent training to enable specialists to able to benefit from subsidised
offending than others. Who is the maximise treatment attendance to our conferences, in The possibilities will be
addiction specialist to tell, and to effectiveness” – maintained by addition to having automatic investigated over the coming
what purpose? And what does it objectives such as encouraging access to the website and receipt months, after which more
mean for a service if all the users pose best practice and knowledge- of the newsletter; however, the information will be available on
this type of risk? sharing, providing support and focus of work has continued to how such links might proceed.
The other complex issue in advice on policy issues and local reflect the main funding source in Any such expansion would have
relation to risk relates to child concerns, disseminating key points England. Earlier this year SCAN an obvious impact on the focus of
on legislation, new guidance and was delighted to be invited by the SCAN’s work, but embracing this
AS LORD DENNING SAID...
current research, encouraging Chair of the Golden Lion Group diversification promises to be very
protection. Substance misusing mentoring, supporting the role of (the Scottish forum for addiction positive. Other similar methods of
parents pose a real risk of emotional specialists; communicating specialists) to attend their gradual and specifically defined
abuse and neglect to their children; specialists' issues and concerns to quarterly meeting to discuss incorporation would apply to
and in a minority of cases also pose a policymakers - and acting as a formalising this relationship. non-psychiatrists as before, to
physical threat. The children of many resource for training including Although some scoping work had ensure the level of specialism
of our patients would be better off workshops, seminars and previously been carried out, remains.
with non-addicted parents; and might conferences. resources and SCAN business had
have a better chance in local authority not permitted us to embark upon Many readers will have been
care. However, being separated from It was generally observed that the such an official expansion prior to involved in preliminary discussions
your parents, however neglectful, may longer-standing SMMGP* this. We are now in a position to about this issue at national SCAN
be more risky to child development in provided a network for GPs with discuss further proposals with the events, and some of the regional
the long term. an interest in the treatment of Scottish Government later this network meetings we have
The emphasis might be better addiction, but those year. Perhaps this will also be attended. Further consultation
placed on helping parents to stop psychiatrists** heading up possible in Wales, N. Ireland and will be carried out, but it is hoped
using drugs and alcohol, not to stop specialist Tier 2-4 treatment the Republic of Ireland in due that these early-stage
them being parents. services were thus far without course. developments demonstrate a
In summary, psychiatrists still have such support. SCAN was to be positive move for the specialty of
a duty to protect patient privacy and jointly supported by the DH, the We have already extended full addiction, and an enhancement
not disclose information without Royal College of Psychiatrists and membership to Staff Grade of a strong representative
consent. In my experience, it is always the National Treatment Agency doctors in England for whom organisation which will continue
a good idea to involve the patient in for substance misuse (NTA). What addiction makes up the entirety to respond to the needs of the
discussion about disclosure to third has developed is a highly of their work. This has tested the professionals on the ground. We
parties; even if this makes for an specialised group of proactive manageability of expanding welcome your thoughts on this
uncomfortable conversation. It is also professionals, many of whom without diluting the specialist matter, and invite you to write to
my experience that, when it comes to contribute to core SCAN activities nature of the network. We now [email protected] to log your
risk, reduction is more likely to be (national conference, SCANbites have 50 staff grades onboard at opinions and suggestions as to
achieved by providing help and quarterly newsletter and website) last! We will be taking the how you see this best achieved.
support than disclosure. in return for opportunities as relevant steps to effect this
Finally, as Lord Denning famously outlined above. change, which includes full Amy Wolstenholme, SCAN
said, “not all that interests the public website access. Coordinator
is in the public interest”. We have a Reflecting on the success of
duty to be sensitive about details of meeting the original remit does Further, we have often received * Substance Misuse Management
personal information and not confuse not mean that we are afraid of comments and suggestions that for General Practitioners
judicious disclosure with gossip. change – quite the contrary. The SCAN’s psychiatry-only approach is **consultants, specialist registrars,
SCAN team has always firmly too exclusive, and that the associate specialists and staff
REFERENCE considered that the organisation organisation ought to echo the grades
1 Confidentiality: NHS Code of Practice DoH should aspire to being UK-wide; multidisciplinary nature of ■A summary of the current SCAN
(2003) www.dh.gov.uk/publications to logically serve the same community drug and alcohol membership is on page 16.
SCANbites, autumn 2008 | 7
SPRS
HEROIN PRESCRIBING IN HOLLAND
Dr Jasdev Grewal goes to find out more...
In August 2007 I visited Holland on a SCAN travelling fellowship
to learn more about the treatment of dependent heroin users
with co-prescribed methadone and heroin. During my five days I
visited treatment centres in different cities and spoke to Fons
Kok, the minister responsible for addictions.
HEROIN WASintroduced as a street drug in with only four choosing to inject. All of the
the Netherlands in the autumn of 1972. The patients are prescribed oral methadone in
total number of heroin addicts in the addition to the heroin. The average daily
Netherlands is currently estimated to be dose is between 80mls and 90mls. This is
approximately 25,000. Most of these ‘chase’ always supervised. None of the patients is
the heroin. using the maximum dose of heroin allowed
Heroin prescribing is only considered - 1g - most used 400mg to 600mg per day,
for chronic users who have not benefited usually in two divided doses, and always
from conventional treatments. This is supervised.
supported by the Central Committee on the Knowledge of the centre is spread by
Treatment of Heroin Addicts (CCBH). word of mouth among the local heroin-
I spoke to the Minister responsible at using population. All referrals are self-
the Health Care Inspectorate in The Hague. referrals. Following an assessment, there is
He explained that there are currently about a four week trial period where the patient
300-400 patients receiving heroin is prescribed methadone by supervised CONFERENCE
prescriptions in Holland in six different consumption with weekly drug testing.
REFLECTIONS
cities. Government expansion plans will see Most drop outs occur during this four week
the initial six centres expand up to 20, with trial period. After this, heroin is prescribed.
15 expected by the end of the year, with a The heroin dose is titrated up and the Memoirs from the 7th
capacity of 815 patients. methadone dose adjusted by mutual
Annual SCAN Conference
Initially there was some opposition consent between the doctor and patient.
for trainees and newly
from the general public about heroin The Rotterdam centre is located only a
prescribing. There was a lot of debate short walk from the city centre. The appointed consultants,
before the prescribing started. This debate location took two years to find and Bath, 12-13 June.
was rational and balanced, with the media arrange. There was considerable opposition Dr Bhaskar Punukollu
taking a neutral stance. The public caution from residents and the city authorities.
and Dr Zarrar Chowdary,
Jasdev Grewal, has now been replaced with a general However, since the centre has opened there
SCAN SpRs
Specialist acceptance.
ALL REFERRALS ARE SELF-REFERRALS;
Registrar, There is now very little coverage in the
KNOWLEDGE IS BY WORD OF MOUTH
Coventry national press about heroin prescribing and
Primary Care even about illicit drug use. Over the past have been very few problems.
Trust five years the national interest has been The centre has 80 patients in total. THE FIRSThalf-day of the conference was
directed towards the increasing levels of There is little aggressive or hostile on “management and leadership in the
alcohol consumption. The country as a behaviour. Patients sometimes try to steal changing world of the NHS”. Dr Haitham
whole is concerned to make alcohol less the heroin but are rarely successful. They Nadeem and Dr Prunwat Bijral, recently
available. Mr Kok said the alcohol/brewing only ever try to steal their own heroin, appointed consultant psychiatrists, gave us
industry would not be able to influence this usually because they want to smoke it later insights into their experiences of working
process. at home. Urine drug screening is no longer as new consultants in the NHS and the
I was shown around the Hague used, as patients tend to be very honest changes they experienced in moving from
treatment centre by their resident doctor. about their drug use. The staff estimate specialist registrar to consultant roles. They
Nearly all of these heroin users are smokers, that of the 80 patients only five use street discussed the importance of working with
heroin. They can ask for an increase in the commissioners toward common goals, the
prescribed heroin if they want, but choose importance of doing meaningful audit as
not to. Street heroin costs €40 per gram. part of clinical governance, and not taking
Heroin has become much cheaper over the on more than you can handle in your
past 5-10 years. workload.
My visit to Holland has been an
invaluable experience. I was struck Ms Annette Dale-Perera from the NTA
particularly by the attitude of tolerance enlightened us on the NTA’s view on
and open-mindedness that prevails in consultant’s role in providing leadership of
Holland. I would like to express my thanks addictions services. She explained the
to Prof. Drummond and Dr Ash Kahn in the relationship between central government,
UK and Prof. van den Brink and Mrs Ineke the National Treatment Agency, strategic
Huijsman in Holland. health authorities, drug action teams, local
8| Supporting specialists, promoting consensus
Introducing the new SCAN SpRs
Following the changeover in August for SpRs, we say goodbye and
thank you to Bhaskar Punukollu and Zarrar Chowdary and welcome
to our three new SpRs who will spend their special interest session
with us for the next year.
Dr Aideen O’Kane
I am a Specialist Registrar in addiction psychiatry currently working
with Dr Eilish Gilvarry in the addiction service
at Plummer Court in Newcastle. My areas of
particular interest are: improving services for
patients with alcohol misuse problems; and
improving the integration of services for
patients with complex co-morbidities.
I am delighted to have the opportunity
to work with SCAN as my special interest
session this year. I hope to use the role to gain a clearer
understanding of the policy and commissioning agenda driving the
future development of addiction services. I would also hope to
develop my writing and editorial skills through involvement with
SCANbites.
commissioners and consultants. management of these. Dr Andrea Hearn
gave us an understanding of contingency Dr Julian Henry
Ms Robyn Doran, service director for management (CM) and explained some of I am an ST5 trainee in general adult psychiatry on the Charing
Central and North West London NHS the potential advantages and pitfalls Cross and St Mary’s Rotation in London. I am
foundation trust (CNWL) substance misuse associated with it. She explained that at currently working in an early intervention
services, discussed the value of shadowing present most research on CM is from the post in West London, and have been using my
a chief executive or medical director. She USA and that services throughout the special interest sessions to get clinical
also said that consultants need to be country have been invited by the NTA to experience in the Kensington and Chelsea
aware of the ever changing policy context take part in a trial of CM acting as pilot Opiate Treatment Clinic, with a particular
in which they work, share knowledge and centres. interest in injectable opiate prescribing. I am
skills and be a “part of the solution rather delighted to be joining the SCAN team as my
than the problem”. The last part of the conference was on special interest session. Over the last year and a half I have
“the future for addiction psychiatrists and experienced at first hand the many challenges that trainees are
Dr Marian De Ruiter, lead consultant in career development”. We gave a talk on now facing following the introduction of MMC. I am particularly
Surrey and Borders Partnership NHS Trust, our experiences of working as SCAN SpRs concerned about the effect that the reconfiguration of training
spoke about the role of addiction and the special interest survey we posts has had on the availability of addictions training for junior
psychiatrists as leaders and gave an conducted, the results of which are now doctors, and I am keen to use my time in SCAN to explore this
overview of how to develop an addictions available on the SCAN website. Prof. Colin further. I believe that SCAN is a hugely important resource for
service. She explained the importance of Drummond discussed the challenges for trainees, and I am really looking forward to making the most of my
understanding one’s own leadership style, the future of alcohol treatment services in year with the team.
and how she had gained insight about her the context of the distribution of funding
own from asking her team to undertake a resources between drug and alcohol Dr Caroline Cooper
360 degree appraisal. treatment. Dr Michael Farrell told us what I am a Specialist Registrar on the mid-Trent Training Scheme – I
the future holds for addiction psychiatrists would like to use my SCAN session to develop
The first part of the second day of the and explained the importance of my knowledge of the addiction field, and to
conference was on “evidence based care developing prison addiction services, new gain experience of how other addiction
and new clinical guidelines”. We had services for older people with addictions, services across the country work. I feel this
fascinating talks in the first section by and other areas of addiction care. Dr Arifur role would also provide me with a better
Dr Judy Myles, Prof. David Nutt and Dr Rahman talked about the possibilities for understanding of psychiatrists’ relationships
Andrea Hearn. Dr Myles discussed the new developing a career in adolescent with our commissioners, policy advisors, and
clinical guidelines from the Department of addictions and his own experiences during the changes all of us in this field may face. It
Health. She explained the importance of his training. will enable me to support the trainees who are faced with
trainees and consultants performing difficulties in gaining the addiction experience they want in light of
clinical audit to ensure that clinical The conference was well received by those the changes in the ST curriculum.
standards set out in the document are who attended and the feedback was very I am also keen to be involved in the planning and running of
met. We were also very fortunate in positive. We welcomed staff grades and conferences, something in which I was involved as a medical
having Prof. David Nutt speak on the associate specialists working in addictions student, and having thoroughly enjoyed the SCAN conferences
neurochemical underpinnings of alcohol this year and the conference had a good which I have attended this year!
and opiate dependence and recent representation from this group. We look
advances in the pharmacological forward to the 2009 conference.
SCANbites, autumn 2008 | 9
HOW TO GET STARTED IN RESEARCH
Qualitative research in addictions
Julia Sinclair considers the practicalities
QUALITATIVE RESEARCH is an umbrella term These questions need alternative methods to The false divide
that includes a broad range of different research provide the ‘best evidence’. However, that is One of the dangers with qualitative research is
methodologies that have their roots in the social not to say that all research using qualitative that it sometimes falls between the chasm of
sciences. These disparate methods are methods is good research; it is very easy to the medical positivist approach that does not
frequently bunched together as a single entity poorly design and execute a study using see it as true science and the lay community
within health services research in an attempt to qualitative methods and then draw spurious who are not trained in critical appraisal and
differentiate them from the range of conclusions from it! see it as appealingly ‘real’.
quantitative methods also used (randomised To illustrate this... Consequently, qualitative and quantitative
controlled trials - RCT, cohort studies, etc). A local DAT commissioned research to research methods are sometimes presented as
Often, the aim of labelling research investigate the needs of women requiring a dichotomy with opposing sides believing in
methods into one of these two groups is to try treatment for substance misuse. The study used the validity of their methods alone. However,
to contrast the differences between them. semi-structured interviews with 20 women and they work best in conjunction, and the need
However, this is analogous to dividing the many focus groups with 16 who had answered an to combine different methods of research
kinds of antipsychotic drugs available into advert inviting them to “air your views on drug enquiry to study complex behaviours and
‘typical’ and ‘atypical’; and by the same analogy, treatment and other related services” in interventions is increasingly recognised.1,2
it would be better to consider the aim of each exchange for a £15 ASDA voucher. The This is due in part to the discrepancy
research project and then use the most authors describe the sample as ‘purposive’ between the efficacy of treatments shown in
appropriate method to study it. (which means chosen to test a particular clinical trials, and the reduced effectiveness of
That said, the fundamental difference theoretical premise) but they should have called these same interventions in routine clinical
between the two groups of research methods is it ‘opportunistic’ (i.e. those people they could practice.3In addition there are some
that quantitative methods tend to be concerned get), as there was no particular theoretical interventions that are not easily (or ethically)
with the measurement of phenomena (e.g. perspective being explored. evaluated by RCTs, and so alternative,
questions asking “how much”, or “how The women interviewed were highly critical methodologically robust designs are needed.2
many”?); whereas qualitative methods are more of aspects of medical treatment including “(that) There are several ways in which qualitative
concerned with the nature of the phenomena the daily collection of medication is experienced and quantitative methods of enquiry can be
under investigation (e.g Why did this happen? by some women as degrading and used together within a plan of research:
How did this occur?). humiliating… leading to continued illegal use”, (cid:129) Qualitative methods may be used as a
without any reference to the safety aspects that precursor, to define concepts which are later
But what about the ‘quality’ of qualitative might be the driving force behind this policy used to inform a quantitative study (e.g. in
research evidence? with individual women. the design of questionnaires, or deciding on
Unfortunately the hierarchical structure used to Yet from these interviews they made 13 the components of a complex intervention);
grade research evidence (see SCANbites 15, recommendations including: (cid:129) Qualitative inquiry may be used at the
p12) was designed to evaluate the efficacy of (cid:129) ‘Improved facilitation of empowerment by end of a study to help interpret the results.
pharmacological treatments within clearly working alongside women’s own harm (cid:129) The ideal situation may be to combine
defined patient populations. Within these reduction strategies to ensure maximum the use of qualitative and quantitative and
confines, there is no doubt that a well engagement’ investigations in a way where each can be
conducted double blinded RCT - or ideally a (cid:129) ‘Availability of crèche or childcare facilities to used to inform the other, and enhance our
meta-analysis of several RCTs - is the best form enable women to avail themselves of understanding of the results found.4,5,6
of evidence. intervention opportunities. Provision must take For example, one may take the results of RCTs
However, this ranking of levels of evidence account of school and nursery times’ of contingency management conducted
has since been applied more generally, and now within the US, and then use qualitative
forms the basis of the ‘strength’ of The DAT have now required the local specialist methods to investigate the feasibility of
recommendations that are given in treatment services to respond to these recommendations implementation within a UK setting. This
guidelines. Research carried out using one of the (with no increase in budget). would allow an investigation of the likely
Dr Julia Sinclair,
qualitative methods fits a different scientific Whilst the study itself is not bad, there are impact of context on the efficacy of the
SCAN Consultant
Psychiatrist Policy paradigm and therefore ranks low down within two fundamental flaws: results.
Advisor and a hierarchy designed to evaluate treatment (cid:129) There is a huge leap between data and More commonly, qualitative methods are used
Senior Lecturer in efficacy. recommendations without any caveats that the after a policy has been implemented to
Psychiatry at the sample is not representative. There is no investigate why it did not have the impact
University of However, RCTs cannot easily answer questions evidence that if the recommendations were predicted by the quantitative studies
Southampton such as: implemented, there would be any behavioural conducted in a different context.
“What are the barriers that prevent hard to change. They confuse people’s opinions about
reach groups (e.g. sex workers) from accessing services with an assumption of causality (i.e. that So what does qualitative research involve?
services?” they would actually change their behaviour if As has already been discussed it is important to
“Why have specific guidelines not been the things they did not like were altered). have a specific aim for the research. This is not
implemented despite evidence of efficacy?” (cid:129) The commissioners have read the report as if it necessarily a hypothesis to be tested, but the
“Why does a new intervention not have the were a hyper authentic view of reality. They are aims of the research, together with a clear
effectiveness that was anticipated?” unable to critically appraise the limitations of the understanding of the nature of the phenomenon
“What are the active components of a complex study design and the lack of generalisability of under investigation, will determine the design
intervention?” the findings. chosen.
10| Supporting specialists, promoting consensus