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Addiction surgeries backlash

As part of a locally enhanced service, our PCT offered GPs £200 per patient per year to provide a service for drug addicts. Two of our four partners were keen to become involved and, with the support of the rest of us, now do four surgeries a week for these patients. Unfortunately, several families have left the practice because they found sitting in a waiting-room full of addicts intimidating. The staff cloakroom was raided during one of these surgeries and we have been broken into three times in the past three months after 27 burglary-free years in the same building. A receptionist is resigning because she fears for her safety. The rest of us want to stop the addiction service, but the two partners accuse us of prejudice

and stereotyping.

GP's advice

Consider holding the surgeries elsewhere

It is not prejudices and stereotyping that have resulted in practices having to be paid a premium to take on the management of addiction problems, particularly maintenance treatment with opioids.

Unfortunately, many drug addicts exhibit odd or aggressive behaviour, steal to fund their habit, and lie to their medical attendants. Whether addiction is due to genetic susceptibility, social pressure or personal choice is not the issue.

You have an obligation to maintain a safe environment for your registered patients and to your staff which, I think, overrides your partners' responsibility to provide treatment for this undoubtedly disadvantaged group of patients.

It would be a pity if your partners had to give up providing a service that they obviously feel is worthwhile and rewarding, and if the practice was to lose the associated income. I wonder whether the surgeries have to be held on the practice premises, or even whether this is the best place for them. Some PCTs offer addiction treatment facilities in a separate location, with a pharmacist on site to dispense prescriptions and supervise consumption, and sometimes a police presence. Ask your receptionist if she will put her resignation on hold while you explore this possibility.

Your partners' defensiveness is worrying. I wonder whether they are experienced and streetwise enough to be taking responsibility for the management of addiction. It is all too easy for an idealistic young GP to be manipulated by flattery ­ saying 'you're the only doctor who has ever understood me' is a tried and trusted tactic in the methadone user's strategy book.

GP's advice

Suspend the service while you evaluate it

It appears that this new service was not sufficiently discussed beforehand in the practice or PCT. Probably the only way to resolve the problem is to suspend the service so the partners, manager, staff and local drug agencies can meet to discuss how and whether it should continue.

The enthusiast partners need to be clear about why they are offering the service ­ it can't just be the money. Undoubtedly the service is worthwhile, especially in an area of high substance abuse, but its incorporation into primary care must be carefully planned. Should the surgeries be just for monitoring and scripting, or should general health matters be addressed in them? It would be sensible for addicts to be scattered as thinly as possible through ordinary surgeries, which would at least prevent the 'waiting room full of threatening addicts' scenario.

The practice needs to formulate and stick to tight policies about mechanisms of scripting, provision of urine samples on demand and at random, DNAs and requests for scripts in unbooked appointments. Joint working with local statutory or charitable drug agencies should be considered: drug workers know a great deal more about drugs than even the most enthusiastic GP, and a drug worker in the practice each week will make the whole service better for the addicted patients and easier for the practice to provide.

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