2. SDF Conference THE NEW GMS ENHANCED CONTRACT Professor Richard Simpson Specialist in Addiction September 30 th 2004

3. Content ● GMS- what is is? ● Size of drug user in primary care ● The new GP contract ● What is happening across Scotland ● Glasgow Fife Grampian ● Lothian the new TAPS service ● Is there a way forward?

4. A Brief History of GMS ● GMS was created in 1948. – Major amendment 1966 – Major amendments 1992- fundholding/first quality initiative for diabetes/asthma/health improvement – New Contract 2004 ● “-heralds fundamental and far reaching changes both within primary care and in the contribution that p.c can make to the NHS” ● “these changes will lead to higher quality care for patients” [John Turner Pay modernisation director GMS NHS Scotland]

5. A brief history of Drug treatment in Scotland ● Needs assessment carried out in 1999 ● Major additional funding commenced in 2000 ● Building to an additional £135m [but including DEA] ● Research indicates 53,000 drug users including 23000 heroin addicts ● Reports including 'Moving On' 'Integrated Care' 'Getting Our Priorities Right' 'Hidden Harm' 'Mind the Gap' 'Psychostimulants'

6. Some Figures on Drug treatment

7. Principles of New Contract ● Designed to deliver Quality ● Designed locally ● Audited locally

8. TOPICS FOR NATIONAL ENHANCED CONTRACTS ● Sexual health ● IP ● IUCD ● Homeless ● Minor injury ● MS ● Depression ● Anticoagulant ● Depression ● Alcohol ● Drugs – –Anti-coagulant –Anti-coagulant

9. Overview of contracts for Enhanced service ● Glasgow -one year contract only ● Forth Valley Lanarkshire Ayrshire and Arran No contract ● Fife temporary contract one year ● Tayside unclear ● Lothian, Argyl and Clyde full contract ● Grampian temporary contract

10. Glasgow Shared Care Scheme ● 129 out of 209 Practices in scheme ● Audit showed – 2% completing treatment – 87% retention in treatment – Mortality 0.7%* [patients in treatment 5891] * lowest recorded level in published literature

11. Glasgow ● Shared care team cocerns about future ● if negotiations don't succeed – All gains in improving Primary care based approach may be abandoned – New integrated CATS teams to manage all drug and alcohol misusers. – New centralised prescribing support to replace both GP and GPDS service

12. Fife ● £250 ● Graduated payments according to work done ● Potential for practices stopping service ● Insufficient capacity in current service ● Increased waiting times – Only Kirkaldy defininite 6weeks up to 26 weks

13. Grampian ● Previous shared care scheme – £120 for treatment – £80 if referring for support ● Temporary new NES contract in place – £240 for maintenance only ● Concerns not enough funding ● Other work in primary care preferable

14. Lothian ● 97/131 practices in old shared care scheme ● 15 opting out with new contract ● 13 opting in ● New total 96/131 in enhanced contract ● New TAPS service to provide for estimated 315 patients displaced by opting out ● New integrated services developing in West Lothian and Mid Lothian and East Lothian

15. Transitional Access Prescribing Service ● Created April 1 st 2004 ● Resource 5 sessions doctor 2 sessions nurse ● Six weeks to created tools and pilot

16. Transitional Access Prescribing Service ● 16 weeks on – 100 patients transferred to TAPS – 5 discharged – 200 await transfer ● Average frequency of appointment 2.3 weeks ● Discharge strategy – Locality clinics – GMSnes practices for Drug treatment only

17. Transitional Access Prescribing Service Problems ● Allocated patients ● New patients on treatment ● Patients from prison ● DTTO completers ● Homeless ● Patients completing residential treatment

18. Problems and Solutions in Lothians ● Specialist services silting up – Referral in from opted out practices – No referral out ● GMS nes practices reaching cap in numbers of drug users ● Locality clinics ● Transfer to GMSnes practices for drug services only

19. Benefits and Risks Nationally ● +ve Payment for Quality ● +ve Locally determined priorities ● -ve Not part of a worked out strategy promoting integration ● - ve No guidance [HDL] ● -ve No core requirements for contract ?value for money. Quality too variable ● -ve Funding inadequate and takes up to high a proportion of the total enhanced servise monies [may be over 25% in Glasgow ]

20. Conclusions Enhanced contracts are a great idea BUT Needs to be integrated in overall drug services Should be a tailored service to fit local need Payment at different levels to suit GP skills and capacity [fife and grampian models] Part of a national strategy with national guidance needed now