Successes and challenges with shared care in London

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Successes and challenges with shared care in
London

• A community drug team viewpoint.

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BAIS

• Started in 1990
• Before this patients were treated by the
  community mental health teams
• I started working there in 1999
• Short waiting times and rapid access
• But revolving door
• Very little prescribing in general practice

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Prescribing at BAIS
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Prescribing at BAIS

• April 2003
• Average dose of methadone 43 mls
• Average dose of buprenorphine 7 mg
• August 2008
• Average dose of methadone 68 mls
• Average dose of buprenorphine 10.8 mg

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Long term clients(over a year in treatment)
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Long term clients(over a year in treatment)
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Long term clients(over a year in treatment)
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Consequences

• Increased number of long term clients in
  treatment
• Increased amount of methadone and buprenorphine
• Increased cost of prescribing
• Reduction in availability of places to take on
  new clients
• log jam

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Consquences

• We need shared care for through put
• GP reluctance
• Patient reluctance
• CDT reluctance
• Shared care workers reluctance
• Pressure from the DAT

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How we use shared care in Bromley

• Appointment of a shared care worker
• Development of a shared care protocol
• Training of GPs
• Primarily part 1 of certificate course
• Sit in with the community drug team doctors
• Gradual introduction of patients
• GPs for prescribing and medical aspects
• Shared care worker for counselling
• Remuneration

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How we use shared care in Bromley

• GPs need
• Knowledge
• Experience
• Local enhanced scheme
• Agreed that any GP can see pts
• Also now seeing patients outside of GP practices

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How we use shared care in Bromley

• Remains shared care
• Shared care worker sits in CDT multidisciplinary
  meetings
• Care is managed by GP and shared care worker
• Can refer back to CDT for advice
• Rapid access to refer back to CDT

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Successes

• Since November 2003
• 30 GPs from Bromley have completed part 1
• 5 GPs have completed part 2
• Have five GP surgeries undertaking shared care
  with two sessions in a hospital setting
• Currently 42 patients in shared care and space
  for another 12
• Seem to be working in partnership
• GPs are comfortable with their roles

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Challenges

• Only one shared care worker who is reaching
  capacity
• Very little development work
• New GPs training ie Part 1
• New surgeries being involved
• GPs gaining further knowledge ie part 2
• Shared care developing
• Reaching capacity

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Challenges

• As a CDT doctor
• Want to know that all doctors we are sharing care
  with have a standard training
• That their boundaries are largely consistent with
  the CDT
• That they keep up to date
• That they are comfortable with their role

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Challenges

• Advanced
• Intermediate
• Basic

Basic prescribers work with SCW who does the
counselling, prescriber does the prescription,
level of part 1 training Intermediate work with
the SCW but SCW is not actively involved but
provides support and advice, level of part 2
training, may be initiating treatment with
support of CDT Advanced NOT shared care,
prescriber can assess and initiate treatment
without involvement of CDT
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Challenges

• As a CDT doctor
• How do I encourage reluctant GPs to be involved
  in shared care?
• How do I encourage basic prescribers to become
  intermediate prescribers (taking on a bigger
  role, doing more training, possibly seeing more
  clients and being paid more)?
• How to I encourage intermediate prescribers to
  become advanced prescribers, independent of the
  SCW and CDT?
• How do I ensure that these prescribers remain
  up-to-date?

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Challenges

• Shared care monitoring groups
• Do they work?
• No GPwSI in Bromley

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The future

• CDTs need GPs
• Patients need GPs normalisation of care
• Massive expansion of GP care needs to be
  continued
• Number of patients needing treatment is
  under-estimated
• Needs training, time and money
• Primary care seen as a cheaper service
• CDTs shift back to manage the complex patients
  as a secondary referral service
• Need the support of the shared care monitoring
  groups and the PCT

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Successes and challenges with shared care in
London

• What are the successes of shared care in London?
• What are the challenges of shared care in London?
• Any unusual or different views?