Innovative Bedford Substance Misuse Partnership

ELFT’s Path 2 Recovery (P2R) substance misuse service team has linked with the De Parys Primary Care Network (PCN) to develop an addiction model of care that supports safer prescribing in primary care and identifies people dependent on prescribed medication who would benefit from formal treatment from P2R.

The model was launched in March 2022 and is now being rolled out to other practices after a successful testing phase that provided:

• Dramatically improved patient attendance compared to traditional clinics
• A supportive approach, maintaining patient dignity and choices
• High success rates in medication reduction
• Prevention of new high-dose opiate prescriptions

The project has been led by Dr Sam Bhima, Clinical Lead and Senior GP with P2R along with PCN lead pharmacist Gemma Davies and GP registrar Dr Toyin Inniss-Agaja.

Dr Bhima said the model was developed to focus on issues including patients referred to P2R by GPs not attending their P2R appointments, interventions not working to reduce medication doses or the numbers of patients on high-dose opioids, and patients who needed treatment for a serious dependence or addiction were not being seen.

No set target of reduction was put in place but the team focused on harm minimization, patient-led approach to changes in dose or type of medication, developing skills for PCN colleagues, offering all patients recovery work with an experienced P2R worker, shared learning and clear communication between practice and P2R.

The team presented details of the work at the Royal College of General Practitioners (RCGP) annual managing addictions in primary care conference held on January 16-17, 2025.

It is the largest event in the UK for GPs, shared care workers, nurses and other primary care staff, specialists, commissioners and researchers interested in and involved with the management of people with addictions in primary care.

“This has been a joint working project which has helped primary care, helped P2R and most importantly helped the people under our care on their journey to recovery,” said Dr Bhima.

“We think the model we have developed is the first of its kind and we have been blown away with how well received it was received by other health professionals.”