We have been promoting the potential advantages of primary care-based drug treatment, including a reduction health inequalities and the stigma associated the use of drugs. Bristol Drugs Project is one of the longest established services in the UK, and they share their experience in the second of a series of case studies on primary care based drug treatment.

How the service came about

During the late 70’s/early 80’s expansion of heroin markets and use in the UK, Bristol’s experience, compared to that of many other cities, was one of a ‘light epidemiological footprint’.  This left the city ripe for major market expansion as mobile phones revolutionised drug supply and the second major outbreak of heroin use in the UK kicked in during the final months of 1992. Other areas followed suit over the next decade. By 1996 Bristol had a new generation of young people, many under 18, who were dependent on heroin.

Our then NHS secondary care provider had developed a two year waiting list for treatment and were effectively shut. Our Bristol GPs who had responded to their adult patients appearing in their surgeries with children who were dependent on heroin, by prescribing methadone, began to feel overwhelmed. GPs across South Bristol gave the Health Authority an ultimatum – get us support or we have to stop prescribing.

A round table came up with two solutions; first, that our NHS provider would open a second prescribing clinic with daily dispensing; second that we should provide support to GPs and their patients within GP Practices. Bristol Drugs Project (BDP) argued passionately for the latter. For four key reasons:

• unlike most secondary care services, whether health, or adult or children’s’ social care, Primary Care can and does flex without falling over or raising thresholds;
  
  
• most people can walk to their GP Practice: Shared Care really is genuinely ‘place-based’ care, rooted in communities;
  
  
• this ‘problem’ was not disappearing anytime soon: Primary Care needed to build their expertise to treat their patients;
  
  
• and most importantly, Primary Care is ‘label free’ and therefore stigma-reducing. When stigma towards people who are drug or alcohol dependent is sadly still alive and well and many people don’t and won’t go near an ‘Addictions’ labelled service, the value of delivering treatment in Primary Care cannot be underestimated.

Commissioned historically by Health and these days by our Local Authority, Bristol City Council, GPs receive a fixed payment for each patient in treatment each quarter while BDP is commissioned to employ a team of Shared Care Workers.

How the scheme works

BDP Shared Care Workers are based in 42 GP Practices. In the busiest Practices BDP staff will be there 5 days a week – key personnel in Practice teams. Around 1800 people receive their Opioid Substitution Treatment through this route at any time, with around 2,300 individuals supported each year. Waiting times are short and other health needs can be recognised and addressed.

Shared Care Workers and GPs complete the RCGP Substance Misuse training and operate within the Standard Operating Protocol developed for the service. Bristol’s treatment service, Recovery Orientated Alcohol & Drugs Service (ROADS) is delivered by a number of organisations. ROADS Consultant Addictions Psychiatrist provides clinical advice to the Shared Care service by telephone and attends GP Practice patient reviews regularly. GPs use a simple (one page) proforma to refer to ROADS. An assessment is then completed and a BDP Shared Care Worker allocated.

A quarterly GP Best Practice Meeting provides key information about patterns of drug use, key treatment service developments and most importantly, gives opportunity for GPs to raise any issue for discussion or resolution.

GPs have membership of ROADS Standards & Governance committee which has responsibility to promote, develop and ensure continuous improvement of all ROADS services and reports into Public Health governance structures.

2022 will mark 25 years of Shared Care OST in Bristol. Of course some of the original GP’s have moved or retired but many remain, passing their expertise to colleagues and offering their patients a service which remains in scarce supply in many other areas. Dr Matthew Barber, a GP at Lawrence Hill Health Centre in inner city Bristol is one of these and shares his reflections on Bristol’s treatment model:

“I have been working alongside BDP Shared Care Workers for over 20 years as an early adopter of the model. It is invaluable to know that when a patient comes to see me with opioid dependency they will meet a specialist drugs worker and have a full assessment within a week. This means people start treatment when they are most receptive to change. Ongoing regular care at the point of need, that is care delivered by BDP Shared Care Workers in our surgery, really improves engagement. Shared Care Workers are an integral part of our clinical team and we communicate regularly about individual patient's care and treatment options. As drug and alcohol-related problems are a substantial part of my workload I am grateful for this collaborative approach.” 

As Dr Barber’s reflections highlight, people across the city, and their families and communities, benefit from this truly ‘place-based’ service, clearly leading the way for the evolution of Integrated Care Systems

Room for improvement?

Always. Two key areas are:

• delivering a more effective holistic health care offer to people engaged in OST -  to really reduce the health inequalities experienced by people who are heroin dependent;
  
  
• growing alcohol detox in Primary Care, especially for those with jobs, families, cultural or religious beliefs, where stigma means they won’t and don’t approach an ‘Addictions’ labelled service until their dependence is really entrenched and much of their recovery capital has likely been shed along the way.

Maggie Telfer, CEO, BDP

Dr Matthew Barber, GP,  Lawrence Hill Health Centre, Bristol