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Addiction, Treatment
Written by Judith Bury   

SUPPORTING GPs IN LOTHIAN TO CARE FOR DRUG USERS

Judith K. Bury, Primary Care Facilitator (HIV/AIDS and Drugs), Primary Care Services, Lothian Health, Edinburgh, UK

INTRODUCTION

Since the mid 1980s it has been Government policy to encourage the involvement of general practitioners in the care of drug users (Medical Working Group on Drug Dependence,1984; Social Services Committee, 1985). Nearly 10 years on, a report from the Advisory Council on the Misuse of Drugs (ACMD, 1993), while emphasising the central role of GPs once again, also acknowledged that there was little evidence of a significant increase in the number of GPs becoming involved. A number of studies have found that GPs are reluctant to work with drug users (e.g. Glanz,1986; McKeganey and Boddy, 1988; Clarke, 1993), although they may be more willing to do so when support is available (Glanz,1986). As the result of one study, the authors emphasise the need to explore alternative approaches to patient management such as the use of practice policies (McKeganey and Boddy, 1988), whereas other authors emphasise the importance of training for GPs ( e.g. Clarke,1993), a point also underlined in the 1993 ACMD Report.

This paper describes how the model of general practice facilitation has been adapted in Lothian to support and train GPs to work with drug users.

THE ORIGINS AND DEVELOPMENT OF FACILITATION

The concept of facilitation in primary care was developed in Oxford in the early 1980s (Fullard et al., 1984) and the first facilitators were health visitors and health educators who supported primary care teams to practise prevention. From the beginning, a key feature of facilitation was the practice visit, to provide 'support, information and expertise to GPs and their practice staff' (Allsop,1990) .

Allsop, ina study of primary care facilitators carried out in 1989,describes how the role of facilitators developed during the 1980s (Allsop, 1990). They were often seen as catalysts of change, supporting primary care teams to implement new ways of working, not only in relation to prevention but also to care. The first facilitator for the prevention and care of HIV infection in general practice was appointed in Oxford in 1987 (Mayon White et al.,1989). In line with the Oxford model, the person appointed came from a nursing background. Another development in facilitation during the 1980s was to employ doctors with general practice experience as GP facilitators, adopting a 'best friend model' (Allsop,1990),based on the concept of 'professional colleague support, a shared view of the world of general practice and assistance in winning resources and sorting out problems' (Allsop,1990).

THE LOTHIAN EXPERIENCE

During the mid-1980s it became clear that Lothian was experiencing two epidemics-one of drug taking and the second of HIV infection which had spread rapidly among injecting drug users (Robertson et al., 1986). This realisation led to a number of responses including the establishment of the Lothian C;P AIDS Support Group, the Community Drug Problem Service and the Primary Care Facilitator Team (HIV/AIDS) .

Lothian GP AlDS Support Group
In 1988 a group of Lothian GPs who were caring for drug users and patients with HIV infection in their practice began to meet with other involved HIV and drug specialists for mutual support. Realising that they had knowledge and experience which they could share with others, this Lothian GP AIDS Support Group began to write and distribute an information sheet ('Local AIDS') to their GP colleagues in Lothian. Later in 1988, with the help of the AIDS Coordinator, the group carried out a survey of Lothian GPs about their experience of HIV infection and drug misuse. The results suggested that there was a need for more training and support to encourage GPs to become more involved in the prevention and management of HIV in the community. In the light of these findings, and of the Oxford experience, the group proposed the appointment of a Primary Care Facilitator (HIV/AIDS).

The Primary Care Facilitator Team (HIV/AIDS)
In 1989 Lothian Health Board appointed a doctor with general practice experience to the post of Primary Care Facilitator (HIV/AIDS) for three sessions a week. By 1992 the team had expanded with the addition of a full-time administrator, a practising GP (for two sessions a week), ensuring that the work of the team remained relevant to general practice, and a former health visitor (half-time), to concentrate on the non-medical members of the primary care team (Bury et al.,1994). The team was funded from the HIV/AIDS and Drugs budget, at first as part of the HIV/AIDS and Drugs Team and subsequently, from 1993, through Primary Care Services of the Lothian Health Board.

The facilitators encouraged primary care teams to become more involved in preventing HIV infection and caring for those already infected by (Bury, 1994a):

• Kunning courses and meetings for doctors and community nurses
• Distributing regular information sheets
• Visiting practices to provide information, training and support
• Developing resources such as leaflets for patients and a combined pill/condom pack
• Encouraging more effective communication between primary care and specialist services.

The work of the team is guided by a steering group which meets six to eight times a year. It is chaired by the AIDS Co-ordinator and includes four general practitioners (one representing the Local Medical Committee) and a community nursing manager among its members.

At first, supporting primary care teams to work with drug users was seen as one aspect of HIV prevention and did not merit special attention from the facilitator team.

The Community Drug Problem Service
With a few notable exceptions (Robertson, ] 985), few GPs in Lothian were involved in caring for drug users until 1988 when the Community Drug Problem Service (CDPS) was established. From its inception the CDPS adopted a shared care approach (Greenwood,1990), encouraging GPs to refer drug users for assessment. The GP continued to see the drug user and to prescribe, while the CDPS worker offered ongoing advice and support to the GP about management. When the CDPS was first established, its staff made frequent visits to practices and were involved in training GPs to care for drug users (Greenwood, 1992). As the CDPS developed. and the level of referrals increased, more of the contact with GPs was by telephone and most advice and support was about care of individual drug users, rather than about working with drug users in general.

Surveys of Lothian GPs were carried out in 1988, soon after the establishment of the CDPS, and again in 1993, to ascertain GP involvement and confidence in managing drug users. Between 1988 and 1993 the proportion of Lothian GPs prescribing for drug users more than doubled from 36% to 73%, (Rosss et al.,1994). Over the same period the proportion of GPs with above average confidence in managing drug users increased from 16% to 34% whereas the proportion lacking confidence fell from 49% to 30% (Ross et al., 1994). Another survey, of a sample of Edinburgh GPs in 1993 (A. Peters, personal communication), suggested that the existence of the CDPS, 'a persuasive, high profile statutory service providing specialist back up and support' was a crucial factor in encouraging GPs to become involved. In two surveys of Lothian practices, it was found that between 1991 and 1993 the number of drug users on substitute prescriptions from their GPs increased by 40% and by 1993 17 out of 76 practices in Edinburgh were each prescribing for more than 20drugusers (Bury,1994b).

The development of drug facilitation in Lothian
As the level of injecting drug use declined and the risk of HIV spread via needle sharing seemed to abate, some GPs were concerned about the rationale behind substitute prescribing. Drug specialists and GPs learned that it often took many years for drug users to come off drugs and that long periods of maintenance prescribing were often needed and some GPs began to question their involvement. A number of practices began to struggle with the problems involved in caring for patients who could often be disruptive and demanding and whose care didn't seem to fit the model of treatment familiar to most GPs (McKeganey and Boddy,1988).

As the involvement of Lothian GPs in caring for drug users increased, they began to ask for support in caring for drug users regardless of their HIV risk. It gradually became clear that there was a need for drug facilitation, not just as one aspect of HIV/AIDS facilitation, but in its own right. In 1994 extra funding was obtained from the HIV/AIDS and drugs budget and, with the support of Primary Care Services, the Infectious Diseases Unit at the City Hospital and the CDPS, the post of one of the medical facilitators was made full time with the intention of developing the work of drug facilitation. This doctor, while working as a part-time facilitator, had also been working part time with the CDPS for four years .

The work of drug facilitation
The main emphasis of drug facilitation has been to work alongside the CDPS, using the approach developed for HIV/AIDS facilitation, to support primary care teams caring for drug users. Drug facilitation now includes the following elements: providing information (and guidelines) for GPs, training, the development of resources, liaison, involvement in planning and audit.

The intention has been to provide different levels of support to primary care teams according to their level of involvement in caring for drug users. Thus, information and guidelines are circulated to all GPs, whereas attempts are made to target training on practices seeing considerable numbers of drug users and on those practices experiencing problems.

Information and guidelines

Since its inception in 1989, the Facilitator Team has been responsible for the production and distribution of a bimonthly information sheet sent to all GPs in Lothian. These 'Local AIDS' sheets, produced in collaboration with the Lothian GP AIDS and Drugs Support Group, have covered a range of topics relat ing to HIV/AIDS issues and at least one sheet each year deals with the management of drug users. Recent sheets have included 'Managing drug users in general practice: some practical aspects', 'Managing drug use in pregnancy', 'Hepatitis C' and 'Recreational drugs'.

The team also informs GPs about changes in services offered by drug agencies by direct circular, via the Local AIDS sheets or via a monthly general newsletter ('GPs ONLY') distributed by the Lothian Area Medical Committee.

One of the facilitators has worked in close c:ollaboration with the Clinical Manager of the CDI'S and with the Medical Prescribing Adviser to produce guidelines for GPs 'Managing drug users in general practice'. This collaboration has encouraged the continuing development of a common approach to substitute prescribing in Lothian which has also led to the introduction of a local voluntary ban on GP prescribing of temazepam capsules and the continuation of a voluntary ban on buprenorphine prescribing.

Training

The Facilitator Team is involved in various kinds of training for members of the primary care team

• Courses and meetings: the team runs one day courses for GPs once or twice a year on 'Working with drug users'. These courses cover topics such as assessment in general practice, the role of the GP, responsible prescribing, managing difficult behaviour and using local resources.

The team also runs a series of evening meetings for GPs in different localities within Lothian. Although these meetings always include a general input on managing drug users in general practice, they also give GPs an opportunity to discuss local issues with workers from local drug agencies.

The Nurse Facilitator runs half day sessions for community nurses, practice nurses, practice managers and reception staff.

• Contribution to other courses and meetings: team members contribute talks on the management of drug misuse in primary care to courses for GP trainees, community nurses in training, practice nurses, practice managers and receptionists.

Practice visits

Members of the team visit practices meet with the doctors, the receptionists, the nurses or with the whole practice team to discuss issues that arise in working with drug users. Practices (via a GP, one of the nursing team or the practice manager) often approach the team to request a visit. Sometimes the idea for a visit comes from liaising with colleagues in the CDPS or elsewhere (see below under 'Liaison'). The practice may be known to be experiencing difficulties in working with drug users or may be beginning to work with drug users for the first time. Sometimes a medical facilitator will visit a practice alone but more often is accompanied by the Nurse Facilitator, a CDPS colleague or both.

The facilitators do not offer advice to GPs about the management of individual drug users, as this is provided by the CDPS. Although the practice visit is often used to impart information or to reinforce advice issued in 'Local AIDS' sheets and guidelines, it can achieve far more than this. When working with the whole practice team, the emphasis is o developing a team approach to working with drug users and, in order to achieve this, the practice visit provides an opportunity for team members to hear one another's views and understand one another's difficulties. The facilitator always acknowledges that working with drug users is difficult and offers ideas, not in the hope of making the work easy but with confidence that they will help to make the work a little less difficult. Both medical facilitators make use of the fact that they have worked in general practice and have experience of working with drug users so that their advice is based on the 'best friend model' and a 'shared view of the world of general practice' (Allsop, 1990). The facilitators encourage practices to adopt policies and to use signed agreements with drug users so that doctors, receptionists, drug users and all members of the practice team are aware of what behaviour is expected of drug users and what sanctions will be applied if an agreement is broken. The facilitators emphasise the importance of consistency of approach, of receptionists being backed up when they are implementing practice policy, and of clear boundaries, combined with a caring and respectful attitude towards drug users. They explain that such an approach not only helps to reduce the stress and chaos that can be associated with caring for drug users in general practice but is also supportive to drug users, and may encourage them to mature out of adolescent behaviour.

At the end of the visit, which rarely last, more than an hour, the facilitator offers to return to discus issues in more detail with different professional groups (e.g. doctors or receptionists) and offers to comment on practice policies or agreements where practices plan to introduce these.

In 1994 the team sent a letter to every GP and practice manager in Lothian informing them of the expansion of the work of drug facilitation and inviting requests for visits. This has led to an increase in requests, especially from practice managers requesting visits for receptionists, and the nurse facilitator now frequently undertakes these alone, offering support and advice to receptionists on managing difficulties in the reception area.

Development of resources

The team has developed a number of resources to support its teaching. These include a video showing scenarios of interviews with drug users in general practice, a model agreement for practices to use with drug users, guidelines for formulating practice policies about the management of drug users, and a leaflet for receptionists on practical aspects of managing drug users in general practice.

The team has also produced leaflets for doctors to give to drug using patients about benzodiazepines and about methadone.

Liaison

Team members remain in close contact with colleagues in statutory and non statutory drug services so that they keep up to date with changes in policy, management and service provision. Services use the team if they wish to communicate changes in their policy or service provision to GPs and the team involves workers from drug services in meetings and courses. A representative of the CDPS is now on the Steering Group of the team.

The team also remains in close contact with primary care so that its teaching remains relevant. Since 1990 the team has convened the Lothian GP AIDS and Drugs Support Group which meets eight to ten times a year and is attended by a regular core of four to five GPs. The Steering Group for the Facilitator team includes four GPs. During 1994 the team carried out a wide consultation process, which included discussions with 16 GPs, throughout Lothian, about its plans for expanding drug facilitation. Members of the team also keep in regular contact with other primary care facilitators and with the pharmacy facilitators.

Planning

Members of the Facilitator Team are involved in a number of planning groups and forums, where they provide a primary care perspective. These include groups updating Lothian Health Board's strategy for drug services and updating Lothian policy on managing needlestick injuries. Members of the team also contribute to discussions about ways of directing resources to primary care teams to support them in their work with drug users.

Audit

The team has carried out a number of surveys of practice distribution of drug users ( Bury, 1 994b), of training needs of GPs (Rossetal., 1994) and community and practice nurses (C. Jaquet, personal communication), and of GPs' involvement and confidence in working with drug users (Ross et al., 1994). The results of these surveys have provided information to support GPs in applying for additional resources and have assisted the team in targeting

training. They have also provided evidence of the increasing involvement and confidence of GPs in Lothian in working with drug users (see above) .

EVALUATING DRUG FACILITATION

The Facilitator Team is just one of many initiatives that make up Lothian's approach to the care of drug users so that it is difficult to distinguish the contribution made by the team from that of other developments and services. There is no doubt that the establishment of the Community Drug Problem Service was crucial in encouraging and supporting GPs to become involved in the shared care of drug users Greenwood, 1990). After a few years it was recognised by the CDPS and by GPs that working with drug users raised issues for the practice that were sometimes best addressed by someone independent of the drug service who was able to look at more general issues rather than at the care of individual drug users.

Since the inception of the Facilitator Team, evaluation of individual activities such as courses and practice visits has provided evidence that these activities are found by the participants to be both interesting and useful (Bury, 1994a), and has also provided feedback that has enabled the team to continue to make such activities relevant. The 'Local A1DS' sheets are well received by GPs. In a survey in 1993,96%ofLothianGPswhorespondedclaimedto read them and 77 % claimed that they kept the sheets for future reference (Bury, 1994a). The team is increasingly used as a resource by both statutory and non-statutory drug services who wish to improve their relationships or communication with general practice and the team's activities continue to be greeted with remarkable good will by GPs and other members of primary care teams. The response rate of 99% achieved in two area wide practice surveys is just one example of this ( Bury,1994b; Burygt al.,1994) .

The practice surveys referred to above (Bury, 1994b) have provided information about the distribution of drug users among practices in Lothian from which it is possible to assess how far the team has been successful in targeting the training offered. From Table 1 it can be seen that practice visits, courses and meetings have been successfully targeted at those practices seeing most drug users.

 

Table 1: Targeting of practice visits, courses and meetings 1992-4


----------
Practices
-------------
with
----------

----------
No
patients
1 - 5
patients
>5
patients
All
patients
Number of practices 38 55 39 132
Visited by
facilitator team (%)
5 20 59 27
One or more doctors
attended course or
meeting (%)
16 42 56 38
Visited and/or doctor
attended course or
meeting (%)
19 53 77 50

*On substitute prescriptions from the practice in 1993 (Bury, 1994b).

CONCLUSIONS

Drug facilitation is just one aspect of the Lothian approach to caring for drug users in the community. Unlike the experience of some areas (Tantam et al., 1993), the Lothian approach has been successful in involving large numbers of GPs in the shared care of drug users (Rossetal.,1994).

Facilitating primary care teams to work with drug users seems to be an essential part of any strategy to encourage GPs to become more involved and to remain involved in this work. The appointment of a drug facilitator is one approach to drug facilitation but is not the only one. For example, many drug services incorporate drug facilitation as an integral part of their work (Blank and Nelles,1993; R Scott, Glasgow Drug Problem Service, personal communication), as Lothian's CDPS also did at first (Greenwood,1990).

It is possible to identify from the experience of the Facilitator Team in Lothian those features of facilitation which contribute to its effectiveness. These are:

• The existence of a statutory drug service encouraging GPs to care for drug users and offering assessment and ongoing support to the individual drug user.

• Someone with experience of general practice and of working with drug users, with teaching skills and the ability to work with tact and diplomacy, appointed at the suggestion of GPs to support GPs.

• Someone with similar skills and a non-medical background to work with the non medical members of the primary care team.

• Adequate administrative and clerical support (at least one full-time post for each full time facilitator).

• A group to steer the work and ensure its continuing relevance to general practice.

• Continuing close collaboration with the statutory drug service. • Active continuing liaison with GPs and with non-statutory drug services.

• Adopting an approach which emphasises the support of GPs and primary care teams to continue with work they are already doing rather than asking them to do more.

These features merit serious consideration by those considering developing drug facilitation elsewhere.

Dr Judith K. Bury, Primary Care Facilitator

(HIV/AIDS and Drugs), The Spittal Street ('entre, 22-24 Spittal Street, Edinburgh EH3 9DU, ScotS land (Tel: 0131<229 5995; fax: 0131-228 182 5) .

ACKNOWLEDGEMENTS

The author wishes to thank members of the Lothian GP AIDS and Drugs Support Group for commenting on earlier drafts of this manuscript and members of the Facilitator Team for their continuing support.

REFERENCES

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