Scanbites Spring 2007 Vol 4 Issue 1

2007·0.85 MB·English

by  Specialist Clinical Addiction Network

ALL DOCTORS HAVE A DUTY TO KEEP UP TO DATE WITH AND ADHERE TO THE CODES OF PRACTICE RELEVANT TO THEIR WORK PAGE 7
The quarterly newsletter of the Specialist Clinical Addiction Network | SPRING 2007 | Vol 4 Issue 1
ISSN 1744-6112
(cid:206) SCAN Addiction Psychiatry Meeting for SpRs and newly-appointed
consultants Francis Hotel, Bath, 7th and 8th June
The road is long...
EDITORIAL
COLIN
DRUMMOND
Alcohol services:
What next?
The publication of the Review of
the Effectiveness of Treatment for
Alcohol Problems1puts into place
the final piece of the jigsaw of
background work envisaged by
the Alcohol Harm Reduction
Strategy for England (AHRSE)2in
relation to specialist alcohol
ALCOHOL TREATMENT WORKS: IT’S OFFICIAL! treatment. Jane Marshall’s article
in this issue of SCANbites
summarises the main features and
T
he Review of the Effectiveness of the UK and North America, where most of the clear strengths of the document.
Treatment for Alcohol Problems1is a Mesa Grande studies were undertaken. It provides compelling evidence
critical appraisal of the evidence-base for The Effectiveness Review takes a broad view of that alcohol treatment works and
treatments available for people with treatment and interventions for alcohol misuse, indeed saves money, as the report
alcohol problems, ranging from simple including hazardous and harmful drinkers as well as summary states: "Evidence-based
advice to intensive specialist treatment. those with alcohol dependence. This view, alcohol treatment in the UK could
Commissioned by the National Treatment Agency consistent with the public health approach, result in net savings of £5 for
in order to inform Models of Care for Alcohol facilitates the delivery of interventions earlier in the every £1 spent for the public
Misusers (MoCAM), it builds upon an earlier drinking careers of individuals, before they progress sector."3It also notes that
unpublished review (Raistrick & Heather, 1998) to dependence, thus preventing medical, "alcohol treatments are highly
and is intended for a wide readership which psychological and social problems and reducing cost effective in comparison with
includes alcohol treatment commissioners and harm. That treatment is delivered in a real world other healthcare interventions,"
providers, alcohol service users and carers, setting is a central theme of the review. notably in comparison to smoking
strategic health authorities and other stakeholders. The evidence for the effectiveness of treatment cessation. So, in line with previous
The objective of the review is to inform for alcohol problems is set out comprehensively in reviews of the alcohol treatment
readers about "those interventions likely to deliver 15 tightly written chapters covering just over 200 evidence base, the conclusion
the best outcomes for people with alcohol misuse pages, no mean feat. The first four chapters set the remains: treatment works. So
and dependence". Due to time constraints, a scene, providing an excellent introduction to the what should happen next?
systematic review was not undertaken. This wide- treatment of alcohol problems for the novice and The AHRSE identified that just
ranging review takes the Mesa Grande project2as an aide memoire for the seasoned clinician. The knowing that treatment is
its starting point and complements this with recent "how" of treatment delivery is discussed as well as effective is not in itself sufficient
systematic reviews from Scotland3, Sweden4and its content. to develop a national strategy to
Australia5. The authors have taken a wider view Chapter 2 takes as its theme "Broadening the improve treatment services. The
than that of the Mesa Grande project, to reflect Base of Treatment and Interventions". This chapter Strategy noted, with some
cultural and service delivery differences between page 2, column 1 ➔ page 2, column 3 ➔
E
U
Dealing with
S
The old problem.
S conflicting
I From other Ilana and Peter
S priorities places... reports Crome consider
I Interview with from Travelling an issue that won’t
H
T Dr Michael Farrell 4 Fellowships 11 go away 14
www.scan.uk.net
EDITORIAL CONTINUED
EFFECTIVENESS REVIEW
Alcohol treatment works! ...what next?
(cid:204) (cid:204)
includes an excellent summary of categories of Pharmacotherapies and their interaction with understatement, that in
alcohol misuse, prevalence and goals of treatment, the psychosocial interventions are discussed in comparison to the area of drugs
including moderation of drinking and abstinence. Chapter 11, specifically detoxification, relapse policy "there has been little focus
Family and friends are included with a plea that they prevention and the role of nutritional supplements. on alcohol treatment" and that
be included as a legitimate unit for intervention. The role of self-help and mutual aid is covered in there is "no national or local
Service user choice and increase in accessibility and Chapter 12, and includes sections on individual self- picture of the amount of demand
responsiveness of treatment are also discussed, help, computer and web-based programmes, for alcohol treatment or the
together with an excellent summary on stepped collective mutual aid (including Alcoholics number and type of treatment
care. This chapter acknowledges the heterogeneity Anonymous), 12-Step facilitation therapy (TSF) and places available; there are no
of alcohol problems and gives commissioners, 12-Step residential treatment. The role of comprehensive standards in the
treatment providers and users a common language, interventions in clients with psychiatric co-morbidity treatment field for access, types of
which should go some way to banishing "the one is tackled in chapter 13; cost-effectiveness of treatment or aftercare; and no
size fits all approach" to alcohol treatment. treatment in chapter 14 and the treatment journey system to allow for the consistent
Chapter 3 is a summary of recent evidence on in context in chapter 15. and coherent commissioning of
treatment effectiveness. Readers are introduced to alcohol treatment services."
the Mesa Grande project, systemic reviews Conclusion
commissioned by the Scottish, Swedish and The authors have presented huge and complex What’s being done so far?
Australian Governments, also Project MATCH and subject in an accessible and readable way and The proposed remedy for these
the United Kingdom Alcohol Treatment Trial should be congratulated for this towering gaps was the commissioning of a
(UKATT). The authors, all members of the UKATT achievement. Clear conclusions are set out at the national "audit of demand and
investigation team and steeped in the work of end of each chapter, also implications for service provision of alcohol
alcohol treatment outcome research, have managed users and carers, service providers, commissioners treatment…[to] provide
to synthesise this recent evidence in a readable, and researchers. Given that the original review was information on gaps between
comprehensive, comparative and insightful way. commissioned in 1997, and there was an earlier demand and provision of
This is as good a summary as one can get. unpublished review in 1998, the authors are to be treatment services and these will
Before going on to review the treatments hugely commended for their dedication and be used as a basis for the
themselves, the authors include two extremely persistence in seeing this review through a long Department of Health to develop
helpful chapters on screening (Chapter 5) and gestation. Distilled in the review is the experience of a programme of improvement."4
assessment (Chapter 6), the latter including a the three authors who have been at the cutting Also the National Treatment
section on outcome measurement tools. edge of alcohol treatment research in an era when Agency was tasked to "draw up a
Chapters 7-10 focus on core psychosocial funding for alcohol research in the UK has been ‘Models of Care’ framework for
treatments for alcohol misuse, including brief parlous, and alcohol treatment services in decline. alcohol treatment services." Both
interventions (Chapter 7); less intensive treatment My hope is that this review will lay the foundations of these tasks have now been
(Chapter 8); alcohol-focused specialist treatment for the rebuilding of alcohol treatment services in completed, the national audit
(Chapter 9); and non-alcohol focused specialist the UK. Treatment works. published by the Department of
treatment (Chapter 10). The evidence for brief How is it then, that in 21st century England, Health in November 2005, and
interventions in hazardous and harmful drinkers only 1 in 18 of the in-need alcohol dependent Models of Care for Alcohol
from a range of settings is set out clearly. The population will access treatment per annum? Misusers in June 20065. The audit
implementation of brief interventions is discussed clearly identified gaps in the
with recommendations on training and support and Dr Jane Marshall is Consultant and Senior provision of and access to alcohol
the need for further research to focus on their Lecturer in Addiction Psychiatry, South London treatment nationally in England,
effectiveness in real world conditions. Less intensive and Maudsley NHS Trust and National Addiction finding that only one in eighteen
treatments aimed at moderately dependent drinkers Centre, King’s College London. people with alcohol dependence
are discussed in Chapter 8 with evidence for gained access to treatment per
condensed cognitive behavioural therapy, brief annum, and Models of Care
conjoint therapy, motivational interviewing (MI) and REFERENCES provided a clear framework for
motivational enhancement therapy (MET). The implementation of improvements
authors make it clear that clinicians should only 1 Raistrick, D., Heather, N. & Godfrey, C (2006) Review in alcohol treatment.
offer MI and MET following appropriate training and of the Effectiveness of Treatment for Alcohol In 2005 DH published a
Problems. National Treatment Agency for Substance
the achievement of a required level of competence. programme of improvement in
Misuse, London.
Chapter 9 reviews alcohol-focused specialist alcohol treatment and pledged an
2 Mesa Grande project (Miller et al., 2003) Miller, W. R.,
treatment, setting out the evidence for the Wilbourne, P. D. & Hetema, J. E. (2003). What additional £15M nationally to fund
community reinforcement approach (CRA); social Works? A Summary of Alcohol Treatment Outcome this from April 2007 onwards6. This
behaviour and network therapy (SBNT); Research. In R. K. Hester & W. R. Miller (Eds.), amounts to some £100,000 per
behavioural self-control training (BSCT); behaviour Handbook of Alcoholism Treatment Approaches: PCT. Our early intelligence
Effective Alternatives, (3rd edition). Boston, MA: Allyn
contracting; coping and social skills training (CSST), suggests that some PCTs are even
and Bacon.
and cognitive behavioural marital therapy (CBMT), now not aware of this funding
3 Slattery J, Chick J, Cochrane M, Craig J, Godfrey C,
all of which have been shown to be effective allocation, and many of those that
Kohli H, Macpherson K, Parrott S, Quinn S, Single A,
treatment modalities. Cue exposure and relapse Tochel C and Watson H. Prevention of Relapse in are aware of it are planning to
prevention are also discussed. Chapter 10 Alcohol Dependence (2003). Health Technology spend this new funding on
summarises non-alcohol focused specialist Assessment Report 3. Glasgow Health Technology developing screening and brief
treatment. The role of families and significant Board for Scotland interventions targeted more at the
others, social skills training, counselling methods 4 Berglund M, Thelander S and Jonsson E (Eds). hazardous and harmful drinkers
Treating Alcohol and Drug Abuse: An Evidence-
and self-esteem and complementary therapies are rather than people with more
based Review (2003). Weinheim, Wiley-VCH.
all reviewed. Although the evidence for these established or severe alcohol
5 Shand F, Gates J, Fawcett J and Mattick R. The
treatments is less than for the treatments in Chapter Treatment of Alcohol Problems: A Review of the problems. How many more PCTs
9, they have the potential to optimise therapist Evidence (2003). Canberra: Commonwealth will simply absorb this additional
characteristics and enhance the therapeutic alliance. Department of Health and Ageing.
2 SCANbites | SPRING 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
OCCUPATIONAL HEALTH
funding into their overall financial REFERENCES
deficits rather than spending it on
alcohol treatment, as the money
has not been ring fenced? 1 Raistrick, D., Heather, N. &
In any case, £15M is a drop in Godfrey, C (2006) Review of the
the ocean compared to the Effectiveness of Treatment for
amount of funding that would be Alcohol Problems. National
needed to realise fully the Treatment Agency for Substance
improvements in alcohol Misuse, London.
treatment envisaged in the scope
of the above reports, 2 Prime Minister’s Strategy Unit
commissioned as part of the (2004) Alcohol Harm Reduction
alcohol strategy, given the high Strategy for England. Cabinet
prevalence of alcohol problems Office, Prime Minister’s Strategy
and the large gaps in treatment Unit, London.
provision. Further, in order to
achieve improvements across the 3 Heather, N., Raistrick, D. &
spectrum of alcohol disorders, Godfrey, C (2006) A Summary of Alcohol and drugs
from hazardous drinking through the Review of the Effectiveness
to established alcohol of Treatment for Alcohol
dependence, there would need to Problems. National Treatment in the workplace
be some strategic overview of the Agency for Substance Misuse,
balance between which parts of London.
Dr Henrietta Bowden-Jones provides an update
the treatment system
improvements needed to be 4 Drummond, D.C., Oyefeso, N.,
made. However, as far as one can Phillips, T., Cheeta, S., DeLuca, P.,
see, this is being left almost Winfield, H., Jenner, J., Cobain, In July 2006, the new Guidance on Alcohol and
entirely to local PCTs to decide, K., Galea, S., Saunders, V., Drug Misuse in the Workplace 2006 was
which is likely to result in a Perryman, K., Fuller, T., published by the Faculty of Occupational
continuation of the postcode Pappalardo, D., Baker, O. & Medicine, Royal College of Physicians. The
lottery of alcohol treatment Christopolous, A. (2005) Alcohol working party was made up of seven
provision we see at present. Needs Assessment Research occupational physicians. Once their input was
Project (ANARP): The 2004 complete they asked me, as the link between the
So what is needed? National Needs Assessment for Faculty of Addictions and the Faculty of
Fortunately, the AHRSE is due to England. Department of Health. Occupational Medicine, to give input from an
addictions perspective. The task was to
be reviewed in 2007 and this
would be a good time to take 5 National Treatment Agency for contribute facts but also give advice on how best
stock of what is now known about Substance Misuse (2006) Models to approach this complex topic. I was delighted
alcohol treatment in England and of Care for Alcohol Misusers. to be involved and very pleased to see all of the
what is needed to improve National Treatment Agency for recommendations included throughout the
treatment services. Also the Substance Misuse, London. book.
In a bout of enthusiasm I had also offered to
government is currently preparing
for the next Comprehensive 6 Department of Health (2005) compile an easy reference guide for the two
Spending Review which will Alcohol Misuse Interventions: thousand occupational physicians who will have
determine the spending priorities guidance on developing a local the guide on their desks at work. This is at the
for the period 2008-2011. Given programme of improvement. back of the guidelines as Appendix A. The
the alarming statistics on rising Department of Health, London. problem of alcohol and drugs misuse at work is
one which is attracting a lot of attention. The
alcohol related harm in England
government estimates that 17 million working
currently delivered almost on a
days are lost annually in England due to alcohol-
weekly basis, and given the cost
related sickness absence. This translates into £6.4
effectiveness of treatment
billion annual loss to employers.
highlighted in the evidence
I would like, in the next few paragraphs, to
review, alcohol treatment is surely
summarise the contents of the guidelines which
a priority in terms of government
are available from the Faculty of Occupational
spending.
Medicine. There are safety-critical occupations
Let’s hope so, because in
which require employers to be extra vigilant in
comparison to treatment for drug
relation to the use of drugs and alcohol, and for
misuse and smoking cessation,
which employees need to have full unimpaired
alcohol currently lags far behind as
control of their physical and mental faculties to
the poor relation, and the
avoid serious accidents. Examples of these
treatment system continues to fail
professions are people who drive regularly for
thousands of people with alcohol
work, those who work in the vicinity of electrical
problems and their families, by
or mechanical systems, those working at heights,
lacking sufficient capacity to meet
those working on railway infrastructures. For
the evidently considerable needs.
these, pre-placement and at times intra-
employment alcohol and drug testing are
Colin Drummond, SCAN lead (cid:204)
SCANbites | SPRING 2007 3
INTERVIEW
OCCUPATIONAL HEALTH
Alcohol and drugs The new era
in the workplace
Changes in medical training, the treatment system
and the NHS: an interview with Dr Michael Farrell
(cid:204)
required. Employees undergoing detoxification Michael Farrell was recently elected to Chair of the Faculty of Addictions of the
should not be employed in safety-critical jobs Royal College of Psychiatrists. He is a Reader in Addiction Psychiatry at the
until they have successfully completed Institute of Psychiatry, King’s College London, and a Consultant Psychiatrist at the
rehabilitation.
South London and Maudsley NHS Trust, where he is responsible for a large
The guidelines advise all employers to
community drug and alcohol service. He is Director of Post Graduate Medical
instigate an organisational policy on alcohol and
Education for the South London and Maudsley Trust. Michael has extensive
drugs in order to be guided in the pursuit of
prevention, treatment and rehabilitation of research interests and is the co-founder and editor of the Cochrane Collaboration
employees and to have legal clarity within the Drug and Alcohol Group, and an assistant editor of the journal ‘Addiction’. He is a
workplace. Training for managers and employees member of the World Health Organisation Expert Committee on Drug
should be provided to promote awareness and to Dependence and has worked on numerous international projects.
educate on essential facts about health and
In this interview with Meredith Mora we find out what Michael hopes to achieve
substance misuse. There is a chapter on testing
as Chair of the Faculty, and what he thinks about the shape of alcohol and drug
procedures, most of which addiction specialists
will be familiar with. However, there is an treatment in a changing NHS.
interesting paragraph on the Data
Commissioner’s Employment Practices Code
(Data Protection) 2005 which states that "the
collection of information through alcohol or drug
What led you to put yourself working with people with alcohol and
testing is unlikely to be justified unless it is for
forward as a candidate for the Chair drug problems, because as we know
health and safety reasons" and that therefore
of the Faculty of Addictions? these are very common problems that
employers should confine testing to safety-critical
affect all health services. One of the
activities. The Human Rights Act 1998 protects Given my experience at a national level
roles of the Faculty will be to promote
the right to privacy and it is therefore current UK as well as my research and training
addictions skills and knowledge across all
practice to only test if safety risks are involved. experience, I decided to put myself
specialities.
In the Fitness for Work chapter the advice is forward. The Chair is an important
that employees suspected of being intoxicated at position in relation to the voices of An addiction consultant who does
work should be suspended and employers must addiction within the policy arena and is a medical student training in psychiatry,
make a full investigation of the circumstances. potentially exciting opportunity to says that she always finds a way to add
Employers have the right to discipline or dismiss influence. in some drug and alcohol training
an employee found to have breached the policy because inevitably those future doctors
in place. In the chapter on treatment and are going to be coming across alcohol
rehabilitation which all of you will be familiar with What do you hope to achieve during and drug problems - in every area of
as a topic, the main drive is toward a your term? medicine - whether they like it or not.
multidisciplinary way of working which involves
Dr Eilish Gilvarry achieved a lot by My thoughts on it have been very well
managers, human resources and occupational
bringing more confidence and coherence articulated by Dr Clare Gerada, from
health staff in order to give employees the best
to the Faculty and its influence, and I RCGP, who said that "every modern
chance of being treated and returning to work
would like to further that. I intend to doctor needs to be able to manage drug
successfully. I have a special interest in
work closely with the different streams and alcohol problems like physicians 50
occupational therapy, and recently held a
of activity, particularly the National years ago needed to be able to manage
workshop on how Career Choices Affect our
Treatment Agency and SCAN. On a tuberculosis." It’s a question of
Mental Health at the Central and North West
specific issue, we’re in a difficult position understanding that modern physicians
London medical conference. I would be happy
with alcohol and the gaps between what and psychiatrists need to have alcohol
for you to contact me if you would like to discuss
needs to be done and what is actually and drug skills as part of their core
any of these issues further.
being done, and I would like to see a competencies. I would hope that
positive change there. Another issue, Modernising Medical Careers’ (MMC)
that I may bring particular value to, is the assessment system results in the
Guidance on Alcohol and Drug Misuse in
impact of the changes to the training development of these core competencies
the Workplace 2006 can be ordered at www.
and career structure of doctors. We and clarity is achieved about the level of
facoccmed.ac.uk/pubspol/pubs.jsp
have to be flexible and responsive and skill doctors need to have in this area.
I’m hoping that I’ll be able to lead a
The single Certificate of Completion of
process where we are proactive and able
Dr Henrietta Bowden- Training (CCT) proposed by the College
to maximise the opportunities for
Jones is Consultant is a proposal that the Addictions Faculty
addiction psychiatry.
Addiction Psychiatrist has been in favour of. Addictions will
Central and North West remain part of General Adult Psychiatry
London Mental Health but the CCT should enable us to clarify
What do you expect those
NHS Trust the specialty component of Addictions
opportunities to be?
treatment and training in a more distinct
I hope that Modernising Medical Careers way than we have previously been able
will bring opportunities nationally for to achieve. In the past we tried to get
Addictions, in terms of ensuring all separate specialty status for Addictions
psychiatrists get basic competence in and failed to do so for national policy
4 SCANbites | SPRING 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
❛❜
International standards and priorities. For the College,
there is the issue of how to maintain
work has
high standards in the context of a
made me changing health system. Where does
appreciate the Faculty of Addictions fit in to that?
Well, probably the key area is the
just how interface in terms of psychiatric co-
much morbidity and dual diagnosis. Many
people with serious mental health
opportunity problems have co-occurring alcohol
we have in and/or drug problems, but our
relationship to that whole area is fairly
Britain.
tenuous. We need to be mindful of the
need to develop better links, both in
terms of general adult psychiatry and
forensic psychiatry.
What are your thoughts about the
shape of addiction psychiatry and its
place in the future?
Regrettably, the alcohol and drug
problem continues to get worse, so the
scale of the need and the response
required is phenomenal. As long as we
take stock of the issues at hand and the
best available means to respond, we will
continue to have a core part to play in
responding to those problems. The
challenge for us as a Faculty is how we
relate to a field in which the number of
stakeholders has increased and will
continue to increase, and there are
potentially conflicting priorities in
relation to those stakeholders. We need
to be politically nuanced, but also
sensitive to the fact that our priorities
are not the only priorities, and that we
have potential to provide leadership, but
we are not the only leaders in the field.
We have an important responsibility to
see beyond our own professional
grouping, to see the wider world and to
operate in it.
How has your international work
influenced your perspective?
In Britain, we are often luckier than we
appreciate, with the structures and the
resource envelope we have to work
within. One of the things travel and
international work has made me
appreciate, is just how much
opportunity we do have in the UK. One
of the absolutely critical resources that
reasons. However, the new system puts on training from a service delivery we have is the human resource, the
all the specialties under the same perspective is going to be huge. So, it wealth of human knowledge from
umbrella that Addictions is currently isn’t simply about new curricula and multiple disciplines. In terms of
under. training systems; it’s also about the new investment, our research capacity could
contexts in which these systems will be
be larger by e.g. American standards,
operating.
but what we achieve with the sorts of
So, how might that impact on
resources we have is remarkable, and
Addictions?
the skill base we have to tap in to as a
What are the other big issues for the
We talk about training in the context of group is by international standards quite
College and particularly the Faculty
the training regulations, which are special.
in the next few years?
important. But I think the other factor
There is a lot happening internationally
we need to be very mindful of is that the Many aspects of general psychiatry,
and the opportunities to influence and
training changes are occurring at a time community care, and mental health
be influenced are substantial. My hope
of potentially profound changes in the legislation are in flux due to changes in
is that we can grasp the benefits of this
NHS, in service delivery, and in the mode the balance between political demands,
in the context of ongoing change.
of commissioning. The influence of that evidence-based practice, and clinical
SCANbites | SPRING 2007 5
ETHICS
3views
An ethical dilemma involving a colleague’s practice
Scenario
THIS CONUNDRUM As a consultant in addiction psychiatry in an established Practitioner involved and refer to the Good Practice
Community Drug Team you have become increasingly Guidelines, however the practice continues and
WAS SUBMITTED
concerned about the practice of a National Health Service communication becomes difficult with the General
BY A SCAN MEMBER
General Practitioner in your area. This General Practitioner Practitioner. You are concerned about the risk of overdose
AS AN ETHICAL
has run a prescribing drug service for Class A drug users and diversion of methadone and diazepam.
DILEMMA FOR from the general practice primary care for many years, and As far as you are aware there have been no adverse
CONSIDERATION has a Service Level Agreement with the Primary Care Trust incidents yet, but you understand from colleagues these
to perform this function. There is a flow of patients issues have raised concerns for several years, and previous
referred from the practice to the Community Drug team. meetings with the GP and the PCT have taken place to try
You have become increasingly concerned about the levels to address them. However many patients prefer the
of prescribing of methadone and diazepam as well as the General Practitioner’s service to that of the Community
supervision arrangements of the prescriptions by the Drug Team due to the perceived differences in the regime
General Practitioner. Examples include patients who are for prescribing and the General Practitioner is considered an
being prescribed high levels of methadone (150mg per day important service provider in the area by the Primary Care
and above), as well as benzodiazepines (150mg diazepam Trust PCT.
per day and above), on weekly prescriptions, while patients
are continuing to use illicit substances. In addition you are The question
concerned about the level of supervision and that patients What are your duties and responsibilities as the local
THE ETHICS OF are initiated on high doses of methadone without a consultant in addiction psychiatry and what steps should
ADDICTION TREATMENT
titration process. You raise your concerns with the General you take, if any, to resolve this issue?
IF YOU HAVE AN
EXAMPLE OF AN ❘❚THE MEDICAL DEFENCE UNION PERSPECTIVE
ETHICAL DILEMMA
WHICH YOU WOULD ...as long as you act ”honestly, promptly (and) on the
LIKE TO SEE
FEATURED IN 3views basis of reasonable belief“
PLEASE EMAIL
[email protected] THISis a sensitive area and you colleague’s conduct, performance or have a log of specific concerns,
have rightly approached the GP in health. The safety of patients must which could then be anonymised, if
question to raise your concerns in come first at all times. If you have appropriate, and forwarded to the
the first instance. As a prescriber, the concerns that a colleague may not relevant person in support of your
GP should be aware of, and comply be fit to practise, you must take concerns.
with, GMC guidance on prescribing. appropriate steps without delay, so If you are not satisfied with the
Good Practice in Prescribing that the concerns are investigated PCT’s response or you feel there is
Medicines (2006)states: "When and patients protected where an immediate risk to patients, the
prescribing medicines you must necessary. This means you must give GMC advises doctors they may wish
ensure that your prescribing is an honest explanation of your to raise the concern with it direct.
appropriate and responsible and in concerns to an appropriate person Whatever action you decide to
the patient's best interests… [and] from your employing or contracting take, it is advisable to discuss the
ensure you are familiar with current body, and follow their procedures." matter with your medical defence
guidance published in the British The supplementary guidance organisation in advance. The GMC’s
National Formulary... including the adds that doctors should not delay guidance reassures doctors who are
use, side effects and reporting a concern because they reluctant to report concerns, for
contraindications of the medicines are not in a position to put it right whatever reason, that they have a
that you prescribe" (paragraph 5). (paragraph 6). duty to put patients’ interests first
Given that you do not feel your You may decide, in line with the and that the Public Interest
concerns about the safety of patients GMC’s supplementary guidance, Disclosure Act 1998 provides legal
have been addressed, you have an that the most appropriate person to protection for individuals who
ethical duty to take action. raise the matter with would be the disclose information in order to
In its recently revised ‘Good clinical governance lead or medical raise genuine concerns and expose
Medical Practice (2006)’ and director at the PCT which malpractice in the workplace. The
supplementary guidance called commissions the service from the GMC adds that doctors "will be able
‘Raising Concerns about Patient GP (paragraph 7). to justify raising a concern – even if
Safety’ the GMC sets out doctors’ The GMC guidance on it turns out to be groundless – if you
6
0 ethical responsibilities to protect reporting concerns adds that have done so honestly, promptly, on
0
U 2 patients from harm if they believe a doctors should be "clear, honest and the basis of reasonable belief and
D colleague’s health poses a threat to objective about the reasons for their through appropriate channels"
M
ht them (www.gmc-uk.org). Paragraph concerns and keep a record of them (paragraph 4).
yrig 43 of ‘Good Medical Practice’ states: and the steps taken to try to resolve
p "You must protect patients from them" (paragraphs 8 and 9). In the Dr Anahita Kirkpatrick, MDU
o
© c risk of harm posed by another MDU’s experience it is invaluable to medico-legal adviser
6 SCANbites | SPRING 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
Consult a defence body before making
your concerns public...
❘❚THE GMC PERSPECTIVE ❘❚THE ADDICTION PSYCHIATRIST’S PERSPECTIVE
Making your concerns In most situations a local, informal
public is last resort approach will work
DOCTORSmust only ever prescribe drugs when DIFFERENTforms of this problem concerned? Initially, offer help. Can
they have adequate knowledge of the patient's are sometimes encountered in any you help the PCT solve the problem
health and are satisfied that the drug serves the substance misuse treatment system. by providing supervision (with a clear
patient's needs, and controlled drugs such as There is no dilemma - it is very clear agreement), helping rewrite
methadone and diazepam demand greater that as a responsible clinician it is guidelines or renegotiate the LES?
caution. Without adequately supervising the necessary to try to do something Talk to the PCT about addressing
patients, the General Practitioner is unlikely to be about it. What is less clear is what resource gaps e.g. lack of supervised
assessing their needs and the patients may well be can be done and how? dispensing. You could suggest they
at risk. While the GP has a Service Level I would try to look objectively at get him external support e.g. SMMGP
Agreement with the Primary Care Trust to provide the evidence you have that there is a (substance misuse management in
the prescribing service, this must not affect the problem. Start auditing referrals from general practice) or via the RCGP
way the GP prescribes for patients. the GP’s service and keep a record. It regional substance misuse leads.
All doctors have a duty to keep up to date is possible that the actual practice is If all the informal methods fail
with and adhere to the codes of practice relevant very different from the rumours. One you need to express your concern
to their work. So the GP, in being a 'specialised or two instances are very much less formally to the PCT for whom he
generalist' must follow the 'Orange guidelines' on worrying than consistently poor works. Find out who the Medical
clinical management of drug misuse and clinical practice. Are there any other Director of the PCT is and send a
dependence. sources of information – what about formal letter expressing your
You are clearly concerned that the GP's the pharmacists? Are there any shared concerns and giving anonymised
patients are being put at risk of overdose, and that care workers who work for you who examples.
the wider public may be at risk from the potential can tell you more about the doctor’s Summarise the informal ways by
for diversion of controlled drugs, made possible practice? which you have tried to change his
by the GP's poor prescribing practice. In It might be worth finding out a practice. It may help if the letter
accordance with Good Medical Practice, you have bit about the GP and the treatment comes jointly from you and your own
a duty to act: the safety of patients must come first system. Has he any training? What Medical Director, or indeed any other
at all times. No adverse incident may have sort of agreement does he have with local senior clinicians. Copy the letter
happened yet but you do not need to wait until it the PCT? Is there a Local Enhanced to the commissioners. Formal
does. You will be able to justify raising a concern - Service agreement? What is he complaints cannot be ignored and
even if it turns out to be groundless - if you have supposed to be doing? Does he have the Medical Director needs to
done so honestly, promptly, on the basis of access to appropriate resources: for investigate the problem and, if
reasonable belief, and through appropriate instance, shared care worker necessary, take action. Offer to meet
channels. support? Are there local primary care the Medical Director, and when you
Try speaking to someone at your employing guidelines? Is he following them? do, discuss ways you and your service
body, perhaps the Medical Director or Clinical Does he say he is following them? can help. For instance, if the GP stops
Governance Lead at the Primary Care Trust. You Think about your own service. prescribing, your service may need to
should follow any Trust procedures and be clear, Are you contributing to the problem have contingency plans in place to
honest and objective about the reason for your by failing to engage complex clients take on the GP’s clients. A referral
concern. Remember to respect patient well enough? Are your policies too from the PCT to the National Clinical
confidentiality wherever possible and inflexible and are you genuinely Advisory Service may provide the PCT
acknowledge any personal grievance you may leaving a number of local service with support to deal with the
have with the GP, but focus on the issue of patient users with nowhere else to go but problems.
safety. Make clear, detailed notes of your concerns the GPs? Look at your own service Finally, you can report a doctor to
and any steps you take to try and resolve them. audits and think about drug doses the GMC. To do so you need very
If you're not sure whether - or how - to raise and whether they really do meet clear evidence of poor practice and
your concern, talk to your medical defence body, clients’ needs. Talk to your user support from other local clinicians
the BMA or the GMC's Standards & Ethics Team - groups and find out what they think such as the PCT Medical Director.
you don't have to give your name. about your service. It is very easy for The scenario describes the worst
If you have done all you can to resolve your services within a local area to become possible case and in most situations a
concerns by raising them with your employers but polarised with one service dealing local informal approach will work.
still have good grounds to believe that patients are with one client group and another Building local relationships across the
still at risk of harm, you may consider making with a different group. whole treatment system can help
your concerns public, provided that patient If you find there really is a address problems early. So
confidentiality is not breached. You should consult problem, start by using informal prevention is better than cure.
a defence body before making a decision like this. contacts to express your concerns.
• This response draws on guidance for Talk to the joint commissioners Dr Emily Finch
doctors from the GMC, namely 'Good informally, but make it obvious how Consultant in Addiction Psychiatry
Medical Practice' and 'Raising Concerns', concerned you are. Are there any South London and Maudsley NHS
both of which can be found on the GMC's other local GPs or GPwSIs who you Trust
website at www.gmc-uk.org/guidance. could talk to who may also be Formerly NTA Clinical Lead
SCANbites | AUTUMN 2006 7 SCANbites | SPRING 2007 7
REGIONAL NEWS
Eastern | Hampshire | London | North
SOUTH WEST also been events on a more local NORTH EAST what is already known, which
basis between psychiatrists and means building therapist
The south-west regional group GPs with a Special Interest The Northeast: NESAG, but competencies to deliver effective
was set up in the mid-1990s. (GPwSIs), where a shared sense of heads high! treatments, which means service
About half a dozen consultants direction has been established. users have real choice of substance
met to support each other, to Next year, we begin inviting SpRs An embryonic meeting of the use goals and style of treatment,
share problems and offer once a year. Northeast Specialists in Addiction which means improved outcomes
solutions. After a cup of coffee, we have Group (NESAG) took place at West at modest cost."
An expanded group now a business meeting that covers Park Hospital, Darlington on 9th All Northeast specialists are
meets quarterly with many of the updates from around the region. November. We once belonged to cordially invited to the next
original members still attending but This is a very supportive and open the Northern Specialists Group meeting at West Park on March
little change in remit. Our part of the meeting, sharing which stretched from the Peaks to 27th, and to contact me about
membership ranges from South difficulties and successes. As many the Grampians and was therefore suggested topics and speakers for
Wales via Gloucestershire to the tip of us are the only consultant in a over-inclusive, particularly following presentations, and items for the
of Cornwall. This makes our region service, this is one of the few devolution. It is heartening that we business agenda.
varied in nature with city chances to have such frank now have enough members in the
deprivation, rurality and discussions. The friendliness of the Northeast and Yorkshire to form Dr Tom Carnwath, Consultant
holidaymakers. This diversity is also group is such that there is no our own group. It is coterminous Addiction Psychiatrist, Tees, Esk and
reflected in our group with a range hesitation in asking colleagues for with the newly amalgamated Wear Valleys NHS Trust
of interests and styles that makes help and advice between the Northeast Division of the College, ●
for lively but supportive meetings. meetings. In my experience, this to which there has been some shift LONDON
We have chosen to usually has been very generous. We also of power away from the Faculties.
meet exclusively as a consultant look at current issues e.g. the new More folk expressed interest
group to allow very free debate but Mental Health Act, or training to than turned up, but enough to The London Drug Dependence
also in view of our increased become RCPsych assessors. take decisions. The company Consultants group
numbers. We are joined by the two Just before lunch, we are included several CAMHS doctors.
regional RCGP leads for part of our joined by our NTA regional lead Colin Drummond and Meredith The London Drug Dependence
meeting which has helped links who updates us on new Mora came from SCAN. Colin Consultants group has a long
with our GP colleagues. There have developments/current issues from described how other regional history of providing a unique
his perspective. This more personal groups worked, which varies quite forum for all Consultants in
contact seems to have been helpful a lot. We agreed to meet three Addiction Psychiatry in London
in showing that consultants times a year initially, with a and the neighbouring counties to
welcome change (most of the business meeting followed by discuss freely a range of topics
time). Locally, the NTA have helped presentations. I agreed to convene relating to national drug issues
to ensure that consultants are now the meetings at West Park for the and specific London issues. The
invited to NTA reviews. first year, which is reasonably easy group continues to meet on a
After lunch, we usually have a to reach (particularly for me!). quarterly basis, organised by
CPD item. This has been diverse Eilish Gilvarry told us of the Professor Hamid Ghodse, with a
with themes from therapy with complexities of medical work with rotating Chair.
horses to driving and addiction. young substance misusers. This led At our June meeting we
Currently, there has been much to lively debate. A subgroup was discussed the new legislation
discussion around the capital proposed to locate all those relating to Controlled Drug
bidding process with some areas prescribing for young people in the prescribing including the new 28
experiencing success in setting up region, to consider and develop day ruling for prescriptions. The
units. There still seems to be a standard protocols across the ability of pharmacists to now
challenge to link this with revenue region, and to move on to an audit correct minor technical errors by
for staffing costs. In other areas, of practice. A regional conference Practitioners on prescriptions will
this process is in the early stages. on this issue was being discussed come as a welcome relief both to
A cup of tea ends the meeting with the NTA. doctors and service users!
with increased consensus and Chris Cook addressed the issue At the most recent meeting
cohesion - and the knowledge that of spirituality and addiction, in October 2006 a range of topics
there are still a few challenges left bringing intellectual clarity to a were covered, one of the most
for tomorrow. subject that can be vague, popular always being the
quarterly drug seizure information
although of huge importance. His
Dr Alison Battersby talk ranged from Hinduism via presented by Chris French, Senior
Chair of the South West William James to Alcoholics Inspector, Home Office Drugs
Substance Misuse Anonymous. We were shown the Branch Inspectorate, Southern
Specialists’ Group value and technique of taking a Region. In this agenda item we
and Consultant brief spiritual history as a standard are privy to the drugs seized, the
Addiction Psychiatrist, part of our assessment. amount and the percentage
Plymouth Duncan Raistrick reported back purity.
Teaching from UKATT, which found that A newcomer to us all is ‘buzz
PCT alcohol treatment is both morphine’, there have been
anecdotal reports but no
acceptable and effective (I simplify
intelligence on this; it is said to be
slightly). The Northeast has the
white heroin. If any of our
greatest mismatch in the country
colleagues have any knowledge
between alcohol need and
of this drug we would love to
treatment available, so hopefully
hear from them. The percentage
commissioners will agree with his
purity of heroin and cocaine
concluding views about what
should happen now: "Implement
8 SCANbites | SPRING 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS
East | South West | West Midlands
HAMPSHIRE AND THE SOUTH EAST
Hampshire Addiction Specialists The membership has been relatively stable and invited him to attend one of our meetings to
although recently two consultant members have allow him to give an overview of developments
The Hampshire Addiction Specialist CPD support retired and it is with regret that I note that only and allow us to have some questions and
group was established in 2002 and covers most one of them has been replaced. Though originally discussion time with him. Latterly we took this as
of Hampshire up to Basingstoke and has also conceived as fulfilling the requirements for an opportunity to invite our colleagues from
included our colleagues in Dorset working in revalidation and also completion of the Royal Sussex for joint meetings, which have been very
Bournemouth and Poole. The group meets College CPD forms, it was quickly established that successful; an opportunity to meet colleagues
quarterly and has grown steadily in size as its members found the chance to meet a good that we would not normally liaise with.
membership has expanded from Consultants only opportunity to discuss local issues or difficulties The recently established South East Region
to include Associate Specialists, Staff Grades and not to mention the pros and cons of retiring. Psychiatrists’ Forum has largely taken over that
Clinical Assistants. Most recently the local There is an informal arrangement that if function and is proving a very popular meeting.
Substance Misuse Specialist Registrars have been there are sensitive issues that consultants alone
invited to attend. The meetings have an agenda wish to discuss, then time will be available for Dr John Crichton, Chair of Hampshire Addiction
and minutes, are held at a central hotel and are that at the end of the meeting where other Specialists and South East Region Psychiatrists’
generally supported by the pharmaceutical members will be asked to leave. Quite early on Forum, Consultant Addiction Psychiatrist
industry. we made contact with the NTA regional manager Hampshire Partnership NHS Trust
EASTERN
seized by the police in this quarter The Eastern Region Addiction Forum consolidated include professionals active in the field outside the
has dropped. There has been an over 2006. Its membership has grown as new Forum and provide an opportunity for discussion,
increase in the number of seizures Consultant Addiction Psychiatrists have been cooperation and coordination of research in the field. It
of anabolic steroids and growth appointed in the region and Specialist Registrars will link up with the basic sciences network active in
hormones. have become increasingly keen to attend. Addictions in Cambridge.
The purchase of drugs over Membership extends to include a physician working The Forum itself continues with its main goal of
the internet also sparked an in the field in the SE region whilst some Eastern region providing liaison and support for consultants working in
interesting debate. addiction consultants based close to London also belong the field and provides an arena for discussing strategies
There is increasing anecdotal to the London Drug Dependence Consultants’ Group. and approaches. It has sought closer links with the NTA
evidence that some of our service The Eastern Region Addiction Forum has facilitated but thus far the Regional Manager has attended only
users are using this route, an active CPD programme with talks ranging from one meeting. There has been subsequent contact with
seemingly able to buy everything frontal lobe deficits in patients with addictions to the Chair of the Forum – and it was hoped that the RM
except diamorphine and cocaine. services for young people with addictions. The Forum would become a member of the Forum and attend
However, there are limited will also deliver a Regional Annual Training Day in meetings routinely. There would be considerable mutual
channels to complain if Addictions for trainee psychiatrists in late 2007. benefit in regular liaison with the NTA.
counterfeit drugs are received! Of A major development planned for 2007 will be the Dr Mervyn London, Convenor of the Eastern Region
note, internet searches are cleverly East Anglia Addictions Research Network which will Addiction Forum, Consultant Addiction Psychiatrist
weighted so that the pro-drug meet quarterly on the day of the Forum. This will Cambridgeshire & P’borough Mental Health NHS Trust
articles appear on the first pages
of your search.
WEST MIDLANDS
In June of this year we held
an away day, extending our with the SMMGP and the West the management of hepatitis C,
regular morning meeting to a full West Midlands Addiction Midlands NTA about ‘best practice and Kerry Webb, who described
day. The two main topics chosen Specialists Group in prescribing for drug users’. his work in assessing candidates
for more detailed discussion and The January meeting was a with alcoholic liver disease or viral
debate on the day were ‘The role The West Midlands Addiction workshop run by Dr David Best hepatitis for liver transplantation.
of the consultant’ and Specialist Meeting has been from the University of Birmingham The July meeting was run by
‘commissioning’. Interestingly running for over 4 years and is about reducing drug related the regional SMMGP leads and
similar themes permeated both open to all doctors working in deaths. This included a description focused on the issue of models of
topics. specialist addiction services across of the situation in Birmingham and ‘Shared Care’ in addiction
A later analysis of the day the West Midlands. In practice this the local strategy for managing the treatment services. Presentations
raised some frustration about not means an even mix of psychiatrists problem, and an overview of the about local practice came from
reaching solutions, whilst for and GPs, with an average evidence base about drug-related clinicians around the region, and
others it was useful being able to attendance of 25. The meeting has harm and drug-related deaths and the audience discussed how to
share information, hear differing always had links with the NTA the effectiveness of attempts at introduce best practice in this area.
views and different ways of West Midlands Regional Office, prevention. There was a particular The first meeting of 2007
working. The London Drug and the Regional Manager is a emphasis on the local initiative to focused on the Birmingham
Consultants’ Group has always regular attendee. Likewise, links empower users to utilise naloxone Treatment Effectiveness Initiative, a
prided itself on being a forum for have been formed with SCAN and to prevent opioid-related overdose. collaboration with the NTA and the
open discussion, rather than the SMMGP; both have an open Last April Abbie Sennett Institute of Behavioral Research at
another meeting with targets that invitation to attend and present. described her work as the drug Texas Christian University. For
have to be met! The topics for the year in liaison nurse in the main acute further details contact Merce
advance are based on suggestions hospital Trust in Birmingham, Morell ([email protected]).
Dr Vanessa Crawford and Dr Sally from the attendees using a leading to a lively debate about
Porter on behalf of the London questionnaire about perceived gaps how to manage drug problems in Dr Ed Day, Chair of the West
Drug Dependence Consultants in knowledge. In 2006, the four other acute hospitals in the region. Midlands Addiction Specialist
Group meetings covered a range of drug She was followed by Katrina Meeting, Academic Consultant
misuse issues, culminating in a joint O’Donnell, a regional hepatitis Addiction Psychiatrist, University
1-day conference in September nurse specialist, who talked about of Birmingham
SCANbites | SPRING 2007 9
SpRs
SpR
CONFERENCE
7-8 JUNE 2007
FRANCIS HOTEL BATH
www.scan.uk.net
for registration
form
Sixth annual SpR
conference update
Dr Mohammad Faizal, SCAN SpR
Many of us will have looked back and
reflected on 2006. As 2007 was ushered in
I am sure we all made resolutions. Don’t
these sound familiar? My visits to the gym How to get ethics approval
have stopped and lettuce leaves are off my
supermarket list again. For those who have
planned to ‘go green’, it must be a hard for your research project
choice making up your mind for the next
holiday!
SCAN had an eventful 2006 and has
plans to match it for 2007. The SpR Presenting your research project for /Audit_or_Research_table.pdf
committee and ethical scrutiny is essetial to protect All NHS RECs use a standard form,
SCAN team the participants, yourself and the available on line at www.corec.org.uk.
have been institution where you are planning to Which REC you approach for ethical
working hard carry out the research. When working review will depend partly on where
to plan the in the NHS this means submitting the you plan to do your research and
next SpR project to a Research Ethics partly on who your participants will
conference. Committee (REC), and the procedures be. For all medicinal trials, research
Hang on! We for doing this have been standardised involving prisoners and research
won’t let many over the past few years. This article has undertaken across more than one
secrets out yet, been written to guide you through the Strategic Health Authority, you should
though we can process of getting ethical approval. apply through the COREC Central
promise an To conduct your proposed Allocation System (CAS). For other
exciting line up research you will need approval from research you should apply through the
of events. We an appropriate REC in addition to that local REC that covers the NHS trust
have got used of the Research and Development from which you will be recruiting
to funding (R&D) department overseeing the site participants. COREC has included a
constraints and SCAN hasn’t been spared from which you are planning to recruit helpful geographical list of REC
either. In spite of a tight budget, SCAN has participants. RECs will only review contacts on their website.
been able to fund fifty percent of the prospective research, and so an You can fill in the application on-
conference. So this year’s conference will application must be made before line and save your progress as you go
again be affordable. conducting your study. You will need along. The form consists of a variety of
Dates for the conference are 7th and approval for any research which questions aimed at helping you specify
8th of June. Please make sure you mark involves past or present NHS patients, the details of your research in such a
this in your diary. The SpR committee users of NHS services and/or their way that it will be clear to the
members were keen to choose a venue families or carers, or NHS staff. committee members exactly what your
down south. The North West has proven REC approval is also required for study involves. Your application clearly
its hospitality by hosting two great research accessing data or medical shows the proposed project’s aims, the
conferences in 2006. This year we are back records. However, work classified as background to the study, the reasons
at the Francis Hotel in Bath. We promise a audit or service evaluation does not why you want to conduct the study
line up of exciting topics by eminent need REC approval, although the and what the expected gains are. You
speakers including Dr Michael Farrell, Dr distinction between this and research will also need to show how you plan
Anne Lingford-Hughes, Dr Eilish Gilvarry, is not always easy. Broadly speaking to identify, manage and minimise risk
Dr Andrew Johns, Prof John Strang and research is hypothesis driven and has to your participants. Your application
Prof Fabrizio Schifano. clearly defined questions, aims and needs to be written in a way that lay
Those of you who are local please let objectives, whereas audit and service members of the committee can
the committee know if there is anything evaluation involve measuring the understand your research, and it is
we shouldn’t miss while at Bath in terms current service with or without often a good idea to let someone
of entertainment and local interest. The reference to a standard. Guidance can without much experience of clinical
finalised programme and registration be found at research look over your application to
forms will be sent out to you in early April. www.corec.org.uk/applicants/help/docs assess its readability.
10 SCANbites | SPRING 2007 | SCAN: SUPPORTING SPECIALISTS, PROMOTING CONSENSUS