Roles and responsibilities of doctors in the provision of treatment for drug and alcohol misusers

This document reflects the findings of a working group set up jointly by the Royal College of Psychiatrists and the Royal College of General Practitioners. The group had the support of the National Treatment Agency for Substance Misuse and the Department of Health. It is intended as a resource for commissioners, service providers and doctors, and seeks to clarify some of the issues surrounding the employment of doctors and deciding which doctors have the appropriate competencies to carry out various tasks in the treatment system.

There has been a large increase in the number of doctors from a range of professional backgrounds working with substance misusers. This increase has mainly been in primary care, as there are shortages of addiction psychiatrists and other experts in secondary care. The expansion in the numbers of general practitioners (GPs) involved has resulted in individual doctors working in different ways, with a variety of competencies. Titles now used include ‘ general practitioners with a special interest’ and ‘primary care specialists in substance use’. The new General Medical Services contract has defined locally and nationally enhanced services, which allow a degree of clarity in terms of the services a GP would be expected to provide to a drug misuser.

All organisations employing doctors need a robust clinical governance structure that addresses issues of education and supervision. The report recommends that appraisal must be carried out by a trained appraiser with experience of the clinical area. Supervision could be carried across different employing and specialty areas, so for example a consultant addiction psychiatrist could supervise a GP with special clinical interest working in their geographical area. Royal College of General Practitioners’ regional leads are another potential source of support. In most circumstances, however, training-grade practitioners should be supervised by practitioners from the same discipline.

In some parts of the country, GPs are working as primary care addiction specialists. There is currently no recognised pathway for these individuals to obtain specialist qualifications, but draft criteria are suggested.

This document defines the following professional groups:

1. • psychiatrists: consultants in addiction psychiatry, consultants in general psychiatry with a special interest in addiction, consultants in general psychiatry

2. • GPs: GPs with a special clinical interest, GPs providing enhanced services, GPs providing core services

3. • other specialists: substance misuse specialists (in primary care), substance misuse specialists (from other professional backgrounds), other doctors on the specialist register, associate specialists, senior clinical medical officers, staff grades.

The competencies expected of each group are summarised. It is acknowledged that individuals will have a range of competencies and skills.

Doctors work within treatment systems and therefore may provide services over a range of National Treatment Agency Models of Care tiers. However, doctors with higher levels of competencies are generally more likely to be working in services that provide Tier 3 and Tier 4 interventions and to be more involved in management and strategic activities. In a treatment system there is a need for services at all levels, with input from GPs and specialists (either addiction psychiatrists or other specialists).