We have been promoting the potential advantages of primary care-based drug treatment, including a reduction health inequalities and the stigma associated with the use of drugs. Cranstoun provide the third in a series of case studies, including a pilot for long-acting buprenorphine in primary care.

Cranstoun Worcestershire is commissioned by Worcestershire County Council with some additional funding provided by the West Mercia Police and Crime Commissioner. Cranstoun have delivered the Worcestershire Drug and Alcohol treatment service since April 2015, when we started implementing our model for shared care delivery in drug and alcohol treatment.

The structure of the scheme incorporates the following:

Governance and Standards

Shared Care Lead (SCL) – The service employs a Shared Care Lead (SCL) as part of the service model.  This role provides a single point of contact for the shared care service and oversees the clinical standards & governance. The SCL role includes the following responsibilities and duties:

• Identifies training needs for shared care prescribers and Cranstoun teams and co-ordinates delivery of relevant training
• Supports the induction of shared care prescribers and new Cranstoun staff, to ensure understanding of the shared care service standards and governance
• Maintains and develops new GP practice partnerships
• Oversees the quarterly claim process
• Communicates service updates and developments to shared care GP practices
• Manages the implementation of new service developments
• Completes annual surgery reviews and audits of the shared care service

Service level agreements – Cranstoun created a shared care Service Level Agreement (SLA) to explain the framework and standards of delivery.

Substance Misuse Treatment Competence – All shared care prescribers are required to attend the RCGP part 1 in the management of drug misuse, funded by Cranstoun. At some GP practices prescribing pharmacists and non-medical prescribers form part of the shared care service team alongside a shared care GP prescriber.

Shared care Surgery Reviews - The SCL completes an annual shared care surgery review. The review confirms shared care delivery against expected standards as per the SLA.  It also provides feedback to shared care prescribers and the Cranstoun worker and recognises good practice whilst addressing any identified issues with service delivery.

Case Audits –At the annual surgery review, the SCL audits the shared care prescribers ‘shared care medical review consultations’ and views this alongside the service user treatment journey recorded on the Cranstoun workers’ case file notes.

Care Pathways and Delivery

Cranstoun Session – A Cranstoun worker is based at the GP practice to deliver psychosocial behaviour change sessions to patients. The number and frequency of the Cranstoun sessions is dependent on the number of patients presenting with substance misuse needs at that setting.  GP practices provide shared care service provision to their own patients but may also provide this to another GP practice’s patients (if the GP practice is not part of the shared care scheme). This is called a ‘Locality surgery arrangement’ with Cranstoun guidance to facilitate this service provision.

Treatment Records –The Cranstoun worker will record session case notes on the patient record as well as the Cranstoun case note recording system to ensure continuity of care and to support effective care planning and risk management.  Treatment plans are documented along with additional screening and health tests including drug screens and blood borne virus screening information. Cranstoun workers are able to book in appointments for patients accessing the service and equally the GP practice can use the system to update the Cranstoun worker on treatment between sessions or to request specific work is completed.

Patient referral - Referral into the service is managed within the GP practice via an ‘assessment appointment slot’ within the Cranstoun session. This enables direct access for the GP to book a patient in for assessment with the Cranstoun worker. This is efficient, auditable and avoids a paper referral process. The practice team also have a greater understanding of drug and alcohol treatment provision and can articulate this to the patient. A patient who attends a GP practice appointment can also leave with a confirmed date for their initial meeting with the surgery Cranstoun worker.

Reviewing treatment - The patient receives psychosocial intervention sessions from the Cranstoun worker and is seen on a regular basis appropriate with their treatment need. The shared care prescriber provides a minimum quarterly face to face medical review with the prescribed shared care patient. These reviews are recorded on the patient record. Patient records relating to the delivery of the shared care service contain detail of medical review discussion and medication prescribing arrangements (where applicable). The review also addresses the patient’s general health needs, monitors the patient’s opiate substitute treatment alongside any other prescribed medications and monitors the patient’s mental and physical health alongside their substance misuse treatment. Three-way medical reviews are scheduled if and when required.

Working in Partnership - The shared care prescriber and the Cranstoun worker meet regularly to formally review those accessing the shared care service to discuss patient concerns, safeguarding, treatment and recovery. Cranstoun also encourage regular face to face discussions between the shared care prescriber and Cranstoun worker and these discussions are documented. 

The Cranstoun worker attends GP practice staff meetings to encourage closer working partnerships with the other GPs and health workers within the practice and to provide information about the service and referral pathways.

Transfer of treatment – Cranstoun has a process to transfer patients from in-house clinic prescribing to a shared care prescriber. This promotes a standard for the case file transfer and acts as guidance for Cranstoun workers to follow each step of the process and to ensure the service user is fully aware of the process. Should the shared care prescriber and Cranstoun worker identify a shared care patient who is no longer suitable for that setting, the process is in place for the transfer from shared are prescriber to in-house clinic and for this to take place as soon as is possible, to support the transfer and alleviate any further issues.   

Duty support – Cranstoun have a daily duty system that is accessible to GP practices/shared care prescribers in the absence of their Cranstoun worker or outside of the Cranstoun session at the GP practice. This support provides a recovery worker, senior practitioner or team leader response when required.

Training and Development

Implementation – The SCL supports GPs when setting up a new shared care practice and all necessary information and guidance is communicated to the relevant persons involved. This ensures consistency with the model and for all involved to have one single point of contact for any queries via the SCL.

Support to shared care prescribers - The Cranstoun Worcestershire Clinical Lead provides clinical support to shared care prescribers. The SCL oversees the shared care service, building relationships with the shared care prescribers and GP practice managers and is available for any inquiries and support. Shared care prescribers are also offered the opportunity to shadow an in-house prescribing clinic for their professional development. Shared care prescribers may request for a shared care patient to be presented at the Cranstoun complex case meeting for multidisciplinary discussion.

Ongoing professional development – Shared care prescribers attend a yearly update and training event that includes briefing sessions, covering a range of topics relating to substance misuse and the logistics related to the delivery of the shared care service. This meeting is facilitated by Cranstoun. It is a mandatory requirement for shared care prescribers to attend one of these sessions. Shared care prescribers also have the opportunity to request a topic to be included within the update and in the past they have requested topics such as ‘Over the counter medications’ and ‘novel psychoactive substances’.

Cranstoun request evaluation forms from these events to ensure these updates remain relevant and beneficial to shared care prescribers.

Service user and shared care prescriber feedback - Cranstoun completes an annual service user survey and has also completed shared care GP and service user surveys. The results from surveys have been useful to support the continued development of this service but also confirms what works well for our service users and the GP practices signed up to shared care.

Long-acting buprenorphine pilot – With the existence of the shared care model framework and the partnerships developed, Cranstoun were able to approach shared care prescribers for their interest in being part of a long-acting buprenorphine pilot. Two GP practices were identified and Buvidal is for the first time in the country, being delivered through a shared care service.

Administration commenced in August 2021 and feedback so far is very positive. The SCL is overseeing the pilot and regularly communicating with and supporting those involved. 

Chloe Baxter-Vickers, Shared Care Lead, Cranstoun