NHS Local Enhanced Service Contract- Drug Misuse Treatment

Revision October 2009

For review: October 2013

Contract Manager: Senior Primary Care Development Manager (DAAT)

1. Introduction

All practices are expected to provide essential and those additional services they are contracted to provide to all their patients.

In Cornwall & Isles of Scilly Drug misuse treatment has been offered under a Local Enhanced Service specification contract since 2005. This document is intended to update and revise this specification, and is designed to cover aspects of clinical care in the treatment of patients who present with drug misuse and dependency which are beyond the scope of general medical services.

No part of the specification by commission, omission or implication defines or redefines essential or additional services.

2. Background

Drug Misuse and its complications pervade every part of society and social classes. The number of class A dependant drug users in the general population in Cornwall & Isles of Scilly is approximately 1750, which is below the national average of estimated 5% of adult population.

Based on National Drug Treatment Monitoring system data, it is anticipated that most General Practices in CIOS will have dependant drug users registered with them.

3. Service Description

This local enhanced service will fund GP practices to deliver prescribed treatment and harm reduction interventions to those patients who present with illicit drug dependency who fulfil the criteria for this level of service and whose treatment needs are commensurate with the competencies of the prescribing GP (Appendix A: Roles and Responsibilities of Doctors in the delivery of drug treatment, CIOS DAAT 2009)

This service will be delivered in partnership with a keyworker from community services under a shared care agreement.

Patients who meet the criteria for treatment in specialist services, e.g. GPwSI or Consultant Psychiatrist in Addictions should not be treated under this enhanced service.

There are several models of ‘shared care’ for drug misuse described by the National Treatment Agency (Department of Health). In order to offer as much flexibility as possible, practices would be able to choose the model of delivery from the following options:

  • Practices who offer an enhanced service for drug misuse, delivered in their own practice to patients registered at that practice only.
  • Practices who offer an enhanced service for drug misuse to their own registered patients and those of other practices who do not offer this LES.

Both options are available under this LES agreement.

4. Aims and Intended Service Outcomes

  1. To facilitate care closer to home
  2. To incentivise GP practices to improve the quality of care to drug users by funding the provision of in-house prescribed treatment for common presentations of drug misuse eg: opiate dependency.
  3. To facilitate an integrated approach to drug misuse treatment that brings together skills from primary care, secondary care and third sector providers.
  4. To facilitate a contractual arrangement in which training and CPD are provided in order to increase the skill base among GPs in treating those with drug misuse.
  5. To integrate drug misuse treatment within general practice to enhance overall health outcomes in this patient group.
  6. To reduce drug related deaths resulting from poor prescribing practice and untreated drug dependency.

5. Service Outline

All GPs providing this LES will provide the following:

  1. Carry out a medical assessment of a patient’s drug use including a full healthcare check and blood borne viruses assessment.
  2. Identify and treat common complications arising from drug use
  3. Provide harm reduction advice and signposting to relevant services
  4. Offer or refer for Hepatitis A & B immunisation and blood borne virus screening/treatment.
  5. Provide evidence based advice and information on the effects of drug use.
  6. Utilise the range of prescribed treatment options for the treatment of drug use, in accordance with the PCT approved prescribing policy and national guidelines described in Models of Care for Drug Misuse, 2002 & 2006 and National Clinical Guidelines for Drug Misuse, 2007..
  7. Monitor patient’s compliance with prescribed treatment. Urine analysis is available for general screening, and for buprenorphine detection, mouth swabs are provided on request from the keyworker allocated to supporting the practice (shared care).
  8. Work as part of an integrated team; in particular maintain close working relationships with the patient’s designated keyworker from (community services shared care), in accordance with the roles and responsibilities described in Roles and Responsibilities of Doctors in the delivery of drug treatment, CIOS DAAT 2009.
  9. If a patient is unsuitable for treatment in the practice, a referral to an appropriate treatment modality (GPwSI or consultant) will be made.
  10. Access continuing relevant supervision, appraisal and professional development opportunities which will be funded by agreement by the PCT/DAAT.
  11. GPs offering this service will be mentored by a designated GP with a Special Interest in Drug Misuse (GPwSI), and have access to clinical supervision with the Primary Care Clinical Lead for substance misuse.

6. Accreditation

All General Practitioners offering this service will demonstrate completion of the SMMGP e-learning modules available through the RCGP Continuing Professional Development training web pages.

Following successful completion of these modules a GP will then undertake an RCGP one day face to face training module within 6 months.

Both of the above constitute the RCGP certificate part I in the management of drug misuse, which is the minimum requirement for delivery of this LES.

Specialist appraisals will be available for those GPs who wish access them, and further training in the specialist area of substance misuse will be available.

All GPs are required to attend at least one local event for continuing professional development in skills for treating drug misuse. The PCT will ensure that these events take place a minimum of 3 times per annum.

7. Quality Indicators

  1. The practice works closely with designated keyworkers from community services to deliver care (shared care) and complies with agreed protocols for onward referral. Quality Indicator: 100% of patients have a named keyworker
  2. The practice has appropriate facilities for the designated keyworkers working in partnership with the GP to arrange face-to-face contact within the practice with patients accessing treatment. Quality Indicator: Practice can demonstrate provision of facilities for keyworker to maintain contact with each patient accessing care under this LES.
  3. Practices are able to offer immunisation for Hep A and B to patients being treated, and their families if applicable. Quality Indicator: 50% of patients and their families who are accessing treatment have been offered or given immunisaton for Hep A & B.
  4. Prescribing data reflects nationally and locally agreed good practice.Quality Indicator: prescribing practice monitored through ePACT reflects this.
  5. Plans of care are devised and agreed in conjunction with the keyworker Quality Indicator: 100% of patients have a care plan that is reviewed at elast three monthly.
  6. Case records and other written documentation relating to treatment are compliant with good practice standards, up to date, and shared between GP and keyworker. Quality Indicator: 100% of records clearly reflect details of treatment, contacts and shared working with keyworker.
  7. GP demonstrates evidence of CPD and access to supervision. Quality Indicator: GP personal development portfolio and specialist supervision reflect development of skills.

8. Governance and Monitoring Arrangements

Monitoring of this Enhanced Service is the responsibility of the PCT and will comprise of three elements:

Performance monitoring may be undertaken in the form of a written survey which will audit certain aspects of the service.

All prescribing will be on FP10 and FP10MDA prescriptions under a dummy practice arrangement known as The Primary care Substance Misuse Treatment Service. Prescriptions pads will be ordered through the keyworker supporting the practice. Monitoring of prescribing practices as recorded on ePACT will be available to the DAAT Pharmacy and Pharmaceutical Group for review and audit.

All GPs offering this LES will demonstrate evidence of continuing professional development relevant to this area of practice, including attendance at least once yearly at locally organised peer support groups & training.

All GPs will have access for advice and information from the GPwSIs in Drug Misuse and the GP Consultant in Substance Misuse.

All practices participating in this LES will comply with the audit requirements of the PCT to monitor and validate treatment practices, including review at annual practice visit.

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9. Funding

Practices will be paid the sum of £150 per patient per quarter in 2010/2011 to provide the LES service, with no retainer payment. This is paid quarterly in arrears.

Practices will be paid according to patient numbers recorded by the keyworker under the National Drug Treatment Monitoring System. Any perceived discrepancies should be discussed with the Senior Primary Care Development Manager (DAAT).

10. Equality and Diversity

This enhanced service will be delivered in accordance with the following legislation:

The Race Relations Act 1976 and amendment 2000

The Disability Discrimination Act 2005

The Human Rights Act 1998

11. Termination of Contract Conditions

This contract is valid for three years and may be terminated by either party given a minimum of three months notice.

Appendix A

Roles and Responsibilities of Doctors in the delivery of drug treatment, CIOS DAAT 2009