The Law of Unintended Consequences

The substance misuse team I work for had the misfortune to be subjected to a partial tendering process a few years ago. The service was split down the middle and tenders invited for the criminal justice side of the service. This has had some nasty and utterly ludicrous knock-on effects. No one considered the Law of Unintended Consequences...

This takes a bit of explaining but stay with me.

The Intention - Background

The Community Drug Team (CDT) used to look after all heroin users - both on the 'core' service side and 'criminal justice' side.

The criminal justice side of the drugs team looks after those users that come to our attention through the courts, through arrests and after release from prison. They are often subjected to drug rehabilitation orders from the courts or are out on licence with specific probation conditions attached to their freedom. The core service looks after everyone else. The contract for the criminal justice work went to a national drugs charity. The CDT was split with half the keyworkers going to the charity to work and the others staying with the core service.

The core work remains in a NHS Trust and the charity uses exactly the same premises with a different set of staff to see the patients. There are now two entirely separate administrative systems running in parallel when there was previously one.

Still with me?

The Consequences - the Law kicks in

Unfortunately, when some muppet at the PCT negotiated the contract they neglected to include anything on the crucially important business of giving drug users Hep B vaccinations and testing them for blood borne viruses such as Hepatitis C and HIV. A fairly basic requirement for this patient population. Despite discussions this remains at a complete impasse.

The core service lost its full-time lead doctor as it can no longer can justify employing a doctor to cover the whole week. This means in the early part of the week they have no one on site to give medical support to the keyworkers, to give advice, see patients, replace missing prescriptions etc. Innovation in the service has ground to a halt.

I work for the criminal justice side. The absence of a contract for Hep B/C means that despite there being a clear clinical need and the fact that I am appropriately trained and fully qualified to administer vaccines, as well as counsel and then test for Hep C/HIV, I am not allowed to do so. I sit within 2 feet of a fridge full of vaccines and a trolley with the tools of the trade for blood-letting. The contract says no. I am supposed to refer the patients to their own GP. Utterly moronic.

While I sit ignoring this travesty of clinical care the keyworkers from the CDT walk past my room bemoaning the fact they have no GP to get advice from on till the end of the week. I am hamstrung when it comes to getting involved. I am powerless to offer any advice as I am, in effect, working in a parallel medical universe.

No prizes for guessing the losers in this inelegant arrangement.

Joined up thinking? Centrally funded? Welcome to the consequences of a health service where we fragment care. It is a nasty little glimpse of the future where the purchaser-provider ethos overrides common sense provision of routine clinical care.