Psychiatric Bulletin (2006) 30: 140-142. doi: 10.1192/pb.30.4.140
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 140-142
© 2006 The Royal College of Psychiatrists
Drug services in England and Wales: a survey of treatment providers and their medical leads
Nick Airey, Consultant Psychiatrist
Somerset Drug Service, Salmon Parade, Bridgwater, SomersetTA6 5PY,
e-mail:
Nick.Airey{at}sompar.nhs.uk
Stuart McLaren, Consultant Psychiatrist
South Devon Drug Service, Torquay
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
We undertook a postal questionnaire survey of drug action teams in England
and Wales with the aim of clarifying the nature of statutory specialist drug
services.
RESULTS
Of 159 drug action teams, 110 (69%) responded; 64 (58%) reported that
mental health trusts exclusively provided their specialist drug services.
Other providers were primary care and acute trusts, the non-statutory sector
and social services. The majority of medical leads were psychiatrists (123
senior posts with 20% vacant/occupied by a locum), then general practitioners
(GPs)(42) and other specialists (4).
CLINICAL IMPLICATIONS
Specialist drug services are offered by a range of treatment providers,
with the medical lead being taken by GPs and other specialists in some areas.
In view of the current difficulty in recruiting psychiatrists, we propose that
alternative training pathways are considered for addiction specialists.
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Introduction
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The past 10 years has been a time of great change for both the
commissioning and provision of substance misuse treatment in Britain. In 1995,
the commissioning of drugs services became the responsibility of local drug
action teams (Central Drugs Co-ordination
Unit, 1995). In 2001, the National Treatment Agency was formed
(http://www.nta.nhs.uk).
This has the status of a special health authority and it is to this body that
the drug action teams are now responsible. The Department of Health published
its consultation document Models of Care for Substance Misuse Treatment
Promoting Quality, Efficiency and Effectiveness in Drug Misuse Treatment
Services in 2002, and this is essentially the National Service Framework for
drug treatment providers.
The provision of substance misuse treatment has also changed considerably
over the years and the landscape today bears little resemblance to that of
even a few years ago. Statutory substance misuse treatment was, at one time,
the preserve of psychiatrists. Much care was provided in the primary care
setting but with a few notable exceptions this was unplanned and
uncoordinated. Psychiatrists had a recognised training route into the
specialty. General practitioners (GPs) have been interested in the provision
of drug services for a number of years but have recently become more organised
and have an active special interest group attached to their College, the
Substance Misuse Management in General Practice.
The ‘traditional’ model of service delivery would be a mental
health trust providing the statutory drug treatment in a particular locality
under the medical supervision of a consultant psychiatrist. However, other
treatment providers have moved into the field; these include primary care
trusts and non-statutory organisations. These agencies require a doctor to
have medical responsibility, but there is no requirement for this doctor to be
a psychiatrist.
We have conducted a survey of drug action teams to investigate the nature
of statutory provision of drug services in England and Wales. We asked who is
providing this care at present, who medically manages these services and the
specialist background of the medical lead. In the UK these statutory services
treat mainly opiate-dependent patients, often with a background of
polysubstance misuse.
Problems in the recruitment and retention of psychiatrists are of major
concern to the Royal College of Psychiatrists and this is a not infrequent
subject for discussion in the Bulletin. The College itself publishes data on
vacant posts (Royal College of
Psychiatrists, 2002). Hence, as part of our survey we also asked
the drug action teams to comment on whether posts were occupied or not.
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Method
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In 2003, we sent questionnaires to all coordinators of drug action teams in
England and Wales by e-mail. Nonresponders were then followed up by letter.
They were asked to provide details of statutory specialist drugs services in
their area, who managed these services, the specialty of the medical lead and
whether these posts were filled, vacant or occupied by a locum.
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Results
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Questionnaires were sent to 159 drug action teams (of which 5 were in
Wales). Usable replies were received from 110 (of which 4 were in Wales),
yielding a response rate of 69%.
Providers
The majority of drug action teams (88/110) had at least one mental health
trust providing drugs services in their local authority area. Of these, 64 had
the service provided exclusively by one or more mental health trusts. The
remaining 24 had a mental health trust provider alongside either a primary
care trust (PCT) (20) or a non-statutory or social services provider (2 each).
Thirty-four had services provided by PCTs, of whom 11 had the service provided
exclusively by one or more PCT provider, 20 in combination with 1 or more
mental health provider and 3 in combination with a non-statutory provider.
Nine drug action teams had services provided by non-statutory services, of
whom three had services provided exclusively by this sector, with the
remainder in combination with other providers, such as a community trust,
mental health trust or PCT. One drug action team had services that were
provided by a combination of social services and mental health trust. The four
Welsh drug action teams which responded indicated that their statutory
provision was provided by acute trusts.
Medical leads
The largest group of medical leads (in posts both vacant and filled) were
psychiatrists. There were 123 senior psychiatric posts, of which 99 were with
a mental health trust, 12 a PCT, 6 the non-statutory sector, 1 a community
trust, 2 social services and 3 acute trusts in Wales. The next largest group
were GPs, the total number of posts being 42, of which 11 were with mental
health trusts, 22 PCTs, 7 in the non-statutory sector, 1 in a community trust
and 1 an acute trust in Wales. Three public health specialists were medical
leads (one in a mental health trust and two in PCTs) and one community trust
employed a genito-urinary specialist as their medical lead.
Post occupancy
Table 1 shows whether posts
were filled, vacant or occupied by a locum. For psychiatrists employed by
mental health trusts, occupancy figures were slightly lower than those in
Table 1 with 75 posts occupied
(77% of the total), 10 vacant (10% of the total) and 12 occupied by a locum
(12% of the total). In PCTs, occupancy was better, with 10 out of 12 posts
occupied (83%). For GPs, 20 posts out of 21 were filled when the PCT was an
employer (95%), and 11 out of 11 for mental health trusts (100%).
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Discussion
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This survey reveals the diverse nature of providers of drug treatment
services. Mental health trusts are still the main providers, but PCTs are
significantly represented. At least nine non-statutory agencies are now
involved in running prescribing services, which is in marked contrast to the
role they occupied not so long ago. Indeed, the future may see a blurring of
the distinction between statutory and non-statutory drug service provision,
perhaps organised under one managerial umbrella. These changes may have
implications for psychiatrists in terms of their professional practice with
issues around, for example, the risk of increased professional isolation in
hybrid provider organisations. They may also have an adverse impact on service
delivery for patients with complex problems, particularly for those with dual
diagnoses (i.e. substance use plus severe mental illness), where there is a
danger of deepening the divide between addiction and mental health
services.
Currently, the conventional route into the specialty of addiction medicine
is through higher psychiatric training, but our survey indicates that there is
diversity in the professional background of doctors now involved, including
GPs and public health doctors. They presumably have a very different depth and
breadth of training experience thus raising major issues of clinical
governance. As a possible way forward in the UK, we would put forward the
Australasian model of a Chapter of Addiction Medicine under the aegis of a
Royal College. Under this system, a training programme would be open to
members of any College, while providing some exemption to psychiatrists who
have undertaken prior addiction training as part of their higher professional
training. This would have the advantage of broadening the entry into the
specialty, ensuring some uniformity of training, and raising and maintaining
educational/training standards in the field. Although a lengthy process
requiring approval by the Secretary of State for Health, development of
training programmes might eventually lead to agreement to a Certificate of
Completion of Specialist Training (CCST) in addiction medicine.
The vacancy and locum rates among consultant psychiatrists revealed in this
survey are very high and possibly increasing. The Royal College of
Psychiatrists’ Annual Census of Psychiatric Staffing 2001
showed a combined vacancy and locum rate among substance misuse psychiatrists
of 14%, compared with our figure of 20%. This contrasts starkly with occupancy
of GP posts of over 95%. Although the reasons for these differences in
occupancy are likely to be complex they must partly be a result of the
relative lack of suitably trained psychiatrists and perhaps the creation of
new GP posts linked to the presence locally of interested GPs. A College
Research Unit study that is currently underway may clarify some of these
factors
(http://www.rcpsych.ac.uk/cru/hsrp/addictionpsychiatricservices.htm).
However, these high vacancy rates add further weight to the need for radical
changes in the routes into addiction medicine training and a corresponding
broadening of the background of addiction specialists.
The main limitations of this study are the possible inaccuracy of the
coordinators’ perceptions of their services provider and medical lead,
and the 69% response rate.
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References
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CENTRAL DRUGS CO-ORDINATION UNIT (1995)
Tackling Drugs Together, a Strategy for England
1995-98. London:TSO (The Stationery Office).DEPARTMENT OF HEALTH (2002) Models of Care
for Substance Misuse Treatment Promoting Quality, Efficiency and Effectiveness
in Drug Misuse Treatment Services. London: Department of
Health.
ROYAL COLLEGE OF PSYCHIATRISTS (2002)
Annual Census of Psychiatric Staffing 2001 (Occasional Paper
OP54). London: Royal College of Psychiatrists.
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Abstract
Introduction
