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Innovative Training Post - Substance Misuse and Homelessness

This guide welcomes you to this exciting post and is intended to maximise your learning. It uses guidance from the GMC, RCGP and other formal bodies, and draws on the experience of previous trainees on the scheme.

The Curriculum Statement written for vocational training by the RCGP covers much of the material that you will meet in this post. However, we encourage you to explore actively your learning needs, and to use the nMRCGP e-portfolio to record your experiences and learning. You will also be expected to do Part 1 of the RCGP Substance Misuse certificate.

This guide contains the information about the Substance misuse and Homelessness post, the supervisory arrangements with relevant contact details.

Homeless people and substance misusers carry a high morbidity and tend not to access health care in the usual ways.

In this post you will gain insights into the health effects of homelessness and substance misuse, and you will learn how to manage disease and substance misuse in the context of significant adverse psychological and social factors. Your experience will be based in general practice and outreach clinics.

Information About the Post

Weekly Timetable

Monday

 

0900

Equinox

1300

 

1400 – 1630

Personal study time/admin/self-directed learning or visits to relevant projects.

Tuesday

 

0900

GP session Villa Street Medical Centre

Telephone calls/scripts/letters/admin

 

 

1400

St Thomas’ Postgraduate Centre – VTS Group

 

 

Wednesday

 

0900

Graham House – Clinic – first 3 months

GP session Villa Street Medical Centre –second 3 months and will include telephone calls/scripts/letters/home visits

1230

 

1400 -1730

Villa Street Medical Practice – Evening Surgery

See emergencies /telephone calls

 

 

Thursday

 

0900 - 1300

Equinox

1400 –1700

Kappa /CDP Opiate Prescribing Clinic

 

 

Friday

 

0900

GP session Villa Street Medical Practice

Telephone calls/scripts/letters/home visits

1400-1600

Tutorial with Dr Frances Diffley

1500-1700

Admin or see Emergencies

The post is split over 4 sites and therefore requires good organisational skills. Your clinical sessions are supervised by 2 different General Practitioners:

Dr Frances Diffley

  • 2 sessions at Equinox
  • 1 session at CDP
  • 3 -4 GP sessions at Villa Street Medical Centre
  • 1 Tutorial session

Dr Richard Wrigley

  • 1 session at Graham House with Dr Wrigley for first 3 months1 session with VTS group
  • 1 personal self-directed learning session

Dr Frances Diffley is a GP at the Villa Street Medical Centre and is your GP trainer and clinical and educational supervisor. In her absence, Dr Julia Hodges or Dr Nancy Kuchemann will provide clinical supervision. Dr Julia Hodges is a GP trainer.

Dr Frances Diffley and Dr Nancy Kuchemann provide clinical supervision whilst working at Equinox. This is a voluntary sector in-patient drug and alcohol detoxification unit. Medical cover is provided 24 hours a day by the practice with out-of-hours cover by SELDOC. The ITP doctor will receive induction and training from the responsible doctors and will then be responsible for doing the medical assessment of residents undergoing detoxification including prescribing the appropriate detoxification regime as well as addressing any outstanding medical problems. The ITP doctor will also be involved in writing discharge summaries to the patient’s GP on discharge.

The ITP doctor will do 3 - 4 GP sessions in Villa Street Medical Centre under the supervision of Dr Frances Diffley.

CDP is a voluntary sector service providing advice to opiate users, shared care support to GPs in north Southwark and opiate substitute prescribing for suitable patients whose own GP will not prescribe. Communication with the patient’s GP about assessment and management is an important aspect of the role. The service includes screening for blood borne viruses and hepatitis B immunisation, counselling and group support to clients.

You will do one session with Dr Wrigley at Graham House for the first 3 months of the job. This is a medium stay hostel for vulnerable homeless people, many with alcohol dependency. The hostel is run by the charity Thamesreach and links into many other organisations which provide support to homeless people from those living on the streets to those in long-term supported tenancies.

Out of Hours

In addition to your weekly timetable, the nMRCGP regulations require you to work one Out of Hours session per month with your clinical supervisor. This will usually take place at the GP cooperative Seldoc.

Click here for contact details

Learning Objectives

  • Develop a working understanding of ‘Drug Misuse and Dependence: UK Guidelines on clinical management’  (DH 2007), models of drug dependency, concepts of harm reduction and the role of medicine in treatment.
  • Develop a concept of the Doctor-Patient relationship and its therapeutic value.
  • Take a drug history
    • Types of drug and alcohol used.
    • Establish type of dependency: quantity taken, length of use, objective indicators (urine testing, withdrawal scales), past treatment episodes.
    • Health complications: physical e.g. viral infection, antenatal care in women: mental e.g. depression, risk assessment.
    • Delivery of health promotion/brief intervention: e.g. family planning, harm reduction, O/D education.
    • Social consequences: e.g. relationship difficulties, housing, criminal justice, and vulnerability e.g. age of patient.
    • Patient goals & expectations/motivation
    • Identifying acute crisis and appropriate management
  • Plan treatment
    • Establishing suitability for primary care management.
    • Knowledge of local agencies: e.g. for specialist/shared care.
    • MDT presentation.
    • Treatment contract e.g. negotiation,  boundaries and roles.
  • Initiate treatment
    • Positive urine screen mandatory, exceptional cases e.g. pregnancy must be d/w consultant
    • Choice of substitute medication
    • Dose assessment and induction (methadone)
    • Symptom control prescribing
    • Stabilisation
    • Detoxification – OPD, IPD
    • Pick up regimes from identified pharmacy
    • Shared care co-ordination
  • Maintenance treatment
    • Regularly r/v D-P goals e.g. methadone maintenance, detoxification.
    • Random urines e.g. 3 mthly.
    • Choice of therapeutic intervention e.g. M-l, relapse prevention, supportive counselling.
  • Manage relapse
    • Triggering factors/high risk situations e.g. relationship breakdown, job loss.
    • Resetting goals.
    • Termination of contract if appropriate: MDT discussion, negotiation, and specialist referral.

Click here to download a self-assessment questionnaire

Roles and Responsibilities

You will sign an employment and educational contract with Dr Frances Diffley.

What you can expect from Villa Street Medical Centre

  • Weekly supervision with Dr Diffley
  • Observe different approaches to treatment from members of the team - nurses, doctors and drug workers
  • Learn about problems and complications related to drug misuse
  • Recognise, assess and plan care of drug misusing patients
  • Manage planned care of drug misusers
  • Understand when referral or shared care with specialist agencies is appropriate
  • Understand issues around testing and treatment of blood borne viruses including pre-test counselling.
  • Start to manage acute and chronic illness in general practice through practice and telephone consultations, visits, repeat prescribing, referral administration and communicating with outside agencies and hospitals.
  • Use recordings, COTS and CBDs to develop communication skills and start to explore different consultation models and explore the GP curriculum in greater depth. Have DOPs supervised by doctors and nurses. Experience multi-disciplinary working through attending meetings (list of attached).

What practices expect from you

  • A commitment to working in multi-disciplinary teams.
  • To familiarise yourself with the relevant information to complete this rotation e.g. the Orange Guidelines on the Clinical Management of Drug Dependence and relevant protocols for CDP and Equinox
  • To provide services as timetabled
  • To plan and manage your workload, and seek additional support if you feel this is necessary

Leave (annual, study or sick leave)

  • Please inform relevant parties ASAP if you are not able to cover a session because of sick leave. The practice will usually have to organise cover at short notice.
  • Please do not take more than 2 weeks planned leave (ie annual or study) at any time
  • Please organise planned leave with as much notice as possible, and a minimum of 4 weeks.

If you have any problems that cannot be dealt with by the appropriate GP please discuss with your Programme Director.

Meetings at Villa Street Medical Centre

Day and time

Attendance and notification

Educational meetings

Monday or Friday Lunchtime 1-2 pm

Once a month

 

All doctors and nurses in on day

E-mail goes around with date in advance and minutes circulated

Clinical meeting

1st Thursday of month

Lunchtime 1-2pm

Organised by Nancy

All doctors and nurses in on day

District nurses

Psychology meeting

Tuesday lunchtime

Every 4-6 weeks

 

All doctors and nurses in on day

IAPTs low intensity and high intensity

E-mail does around with date in advance and minutes circulated

Counselling meeting

Tuesday lunchtime

Every 8 – 12 weeks

 

All doctors and nurses in on day

Penny and Ellie – counsellors

E-mail goes around with date in advance and minutes circulated

Palliative care meeting

Monday or Friday Lunchtime every 3 months

 

All doctors and nurses in on day

Palliative care team representative

E-mail goes around in advance and minutes circulated

Equinox meeting

Tuesday lunchtime

Every 3 months

Organised by John at Equinox

All doctors working at Equinox if possible

Nurses from Equinox

Liz – manager

E-mail in advance with date and minutes circulated by John

Mental Heath meeting

These have lapsed

Every 3-4 months

 

Psychiatrist attends

Dr Walters

E-mail will be sent around with date – minutes to be circulated

 

Substance misuse supervision meeting

Tues/Wed/Thursday lunchtimes 12.45 – 2.30pm day alternates

Every 6-8 weeks

 

Doctors interested who are here on day

Local GPs on LES

Emily Finch – Consultant Psychiatrist

E-mail goes around and minutes circulated

Practice meeting

Lunchtime

Day varies

Organised by Practice manager

All surgery staff who are here on day

E-mail goes around with date and minutes circulated

 
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