02 November, 2020
Dr Joe Tay is a GP who was working at Edinburgh Harm Reduction Team in Edinburgh and is passionate about the new Medically Assisted Treatment Standards and had undertaken a test of change to demonstrate the impact on the people who used the service when working with a low threshold model.
One of the most frustrating things about being in a caring profession such as medicine, nursing, social care etc. is the feeling of helplessness, anger and sadness when you feel you have to say no to a plea for help.
Often this is because of our gatekeeping role within the NHS, other times it is because of our lack of knowledge around local systems and processes, and unfortunately, sometimes, it is because the systems of care provision we work within are not designed with the needs of our patients in mind.
It is important to say, before I go any further, that gatekeeping can be an important role. I remember as a trainee GP, getting very upset with a palliative care consultant when a patient I was seeing who was clearly suffering was not being allowed a bed in a local hospice. Once the settled down, the very kind consultant took time to invite me over to the hospice to show me around, and explained that if they did not manage their beds carefully, they could not respond to people in their last days of death. People in their last weeks had to be managed at home with all the support we could provide for this reason.
What then about people who are using street drugs who come to us for help? Who are we helping by saying no to them when they come, cap in hand? As is good practice in the NHS, I decided to audit a series of patients who came to me after being on a waiting list for management of opioid dependence.
Looking over 15 patient files, I noted that after being assessed, they waited on average 74 days before starting on a script. Within this group:
- 33% were injecting drugs.
- 20% HIV positive.
- 33% had COPD,
- 33% unstable housing,
- 20% learning disability, 40% had debt or benefits issues.
While waiting for opiate replacement therapy (ORT), none of these people were in any kind of position to manage their other health problems. After they started treatment, they then were able to tackle some of their other issues.
Using this information, I decided to try something different. First, I looked at the Orange Book, last updated in 2017 to see what the experts say about keeping patients waiting. The guidance is clear. People should not be kept waiting unnecessarily for ORT simply to complete long comprehensive assessments. Where the diagnosis of opiate dependence is clear, and the person fully understands their options, and it is safer to do so than not, then ORT should be initiated. The rest of the assessment can be carried out when the person is feeling better.
So that’s what we did. When people attended our drop in the Salvation Army Niddry Street Wellbeing Centre or at the Harm Reduction Team in Spittal Street and asked for help, we said YES. And it has been transformational.
35 people came to our drop in over 2 months. 93% received the treatment within 24 hours. Interestingly, almost all of them had additional needs that they had not been able to deal with until after treatment had been stabilised. This included issues with benefits, food poverty, HIV and HCV, homelessness, depression and COPD. We were able to help with all of these problems roughly at the same time as ORT was initiated- on the day they came for help. So…. This is what happens when you don’t have to say no!
A poster visualisation of this initiative is available here