ℹ️ This is the case information for the doctor.
Name
Ketan Mistry
Age
20
Address
Temporary resident
Social history
Smoking status: Smokes 10 roll-ups a day
Alcohol intake: Does not drink alcohol
**Alcohol intake:** Does not drink alcohol
Past history
Drug use: Heroin addiction for 18 months
No regular GP contact
Investigation results
BP 116 / 72
BMI 17
No previous investigations available
Medication
None
Booking note
Seen at new patient check by nurse. Asking for help to 'kick his heroin' habit.
ℹ️ This is the information for the person role playing the patient.
Name
Ketan Mistry
Age
20
Address
Temporary resident
Social history
Smoking status: Smokes 10 roll-ups a day
Alcohol intake: Does not drink alcohol
**Alcohol intake:** Does not drink alcohol
Past history
Drug use: Heroin addiction for 18 months
No regular GP contact
Medication
None
"I really need your help, doctor. I need to get off this heroin that I’m on."
Has been using heroin for “a while”, escalating to daily injecting over past year or so
Feels life has "gone to bits" through drug use
Mood low but focused on “wanting to make things better”
Background information
Recently a friend overdosed (survived); this was a wake-up call
Injects heroin a couple of times a day, smokes it once or twice a week
Sometimes uses cannabis to come down
Has started injecting into groin/genitals because peripheral veins are too damaged
Shares and reuses needles due to lack of clean supply
Living situation unstable (sofa surfing, sometimes sleeping rough)
No relationships or close contacts unaffected by drug use
Estranged from mother and ex-partner after stealing from them
Lost weight over the past year; self-care is poor (“not been eating, not drinking much”)
Further details about problem and presentation:
Started heroin use ~18 months ago, escalated over time
Initial use attributed to friends offering drugs, started with “speed” before heroin
Never tried to stop before; this is first attempt at seeking formal help
Physical health: No active swelling/redness at injection site now but admits to injection-site problems in the past; only current symptom is weight loss
Bowel function normal
Ideas
Believes taking heroin is ruining life relationships, wants to get "off it" and get his life back
Thinks methadone is a simple, immediate solution (“thought you’d prescribe me some methadone and things will start getting better”)
Concerns
Motivated by fear following friend’s overdose—worries about dying or suffering similar harm
Concerned about ongoing estrangement from family
Embarrassed about injection sites, feels ashamed about stealing from loved ones
Worried about living situation, especially as winter approaches
Expectations
Expects to be given a prescription for methadone today and to start “getting stable” immediately
Hopes to use methadone to rebuild relationships and regain control of life
Not particularly focused on social services, feels getting “clean” should come first before addressing housing/food/etc.
Interested in needle exchange services if mentioned
General behaviour:
Appears anxious, fatigued, somewhat malnourished
Emotional, wavering between shame, guilt, and hope
Grateful for empathy and practical help but somewhat withdrawn if met with disinterest
Shows increased willingness to discuss sensitive issues (e.g., injection sites, needle-sharing, stealing) if the doctor is non-judgemental and supportive
Easily frustrated if feels dismissed, particularly about not getting methadone straight away
If doctor explains reasons for referral rather than instant prescription with care and hope, will accept this plan, especially if his motivation is validated
Some reluctance about engaging with social services; may accept if reasons are well-explained and linked to wider recovery
Specific Cues:
If doctor expresses open, honest curiosity and concern, Ketan opens up about details of drug use, social history, and hopes for recovery
Offended or defensive if feels judged for needle-sharing, unusual injection sites, or stealing
If asked appropriately, will admit to stealing from family due to desperation, not malice
If offered onward referral, agrees but wants reassurance this is a genuine step towards recovery
If social prescribing/social assistance is mentioned, initially dismissive but comes round if linked to safety and recovery
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
Begins with open questions, allowing Ketan to explain his concerns and what prompted seeking help now.
Progresses logically with targeted closed questions on heroin use patterns, routes, frequency, other drug use, and physical symptoms.
Data gathering was incomplete, lacking structure and focus.
Jumps between topics without a clear structure and omits key information such as specific patterns of use, associated risks, and symptom chronology.
Fails to clarify what led Ketan to attend or the impact of current health and social stressors.
Makes effective use of existing information and considers the wider context.
Uses cues from Ketan’s homelessness, estranged relationships, and financial strain to guide focused questioning about social support, risks, and treatment engagement.
Incorporates background information and patient concern to build a comprehensive picture of daily life and challenges.
Fails to use the information provided or understand the wider context.
Ignores clear social cues—homelessness, family breakdown, recent theft—and fails to connect these to current risk, engagement, or safeguarding needs.
Does not explore or contextualise how external factors impact treatment options and health.
The presence or absence of relevant red flags was established.
Enquires about acute overdose, injection site infection, DVT, blood-borne viruses, and unexplained weight loss.
Checks for current withdrawal, risks of acute harm, and any other urgent medical complications of heroin use.
Fails to assess key information necessary to determine risk.
Does not ask about high-risk behaviour such as needle sharing, recent overdose, withdrawal history, or signs of sepsis.
Misses key acute risks including physical harm or suicidality relevant to this demographic.
Information gathered placed the problem in its psychosocial context.
Enquires about psychological impact, family and social relationships, social isolation, and day-to-day functioning.
Explores Ketan’s attitudes to change, coping strategies, shame, and hopes for the future.
The social and psychological impact of the problem was not adequately determined.
Does not explore the psychological effects of addiction in sufficient detail, missing issues such as mood disorders, self-esteem, self-harm, or risk to self/others.
Does not follow up on patient’s admission of criminal activity (stealing), or delve into financial precarity and its consequences for mental health and safety.
Revises hypotheses as necessary in light of additional information.
As further social, psychological, and physical symptoms are described, adapts questions and refines both risk assessment and differential diagnosis to reflect new findings (e.g., significant weight loss and social breakdown prompting broader health screening).
Adjusts the approach when patient mentions new factors such as criminal activity or worsening mood.
Rigid consulting with new information not adequately considered and integrated into the working diagnosis.
Fails to pursue important cues about criminal activity, relationship breakdown, or deterioration in functioning, resulting in a less tailored and less safe assessment.
Does not sufficiently update diagnostic reasoning in response to new disclosures, risking missed risks or complications.
A working diagnosis was reached using a structured, evidence-based approach.
Collates evidence of opioid dependence from frequency and duration of use, supports this with targeted questioning about withdrawal and previous attempts to stop, and contextualises risk factors for harm (homelessness, sharing needles). Demonstrates structured thinking about likely complications and severity.
The evidence collected was inadequate to support the conclusions reached.
Does not adequately verify opioid dependence with a formal symptom history (criteria for dependence, tolerance, withdrawal) or clarify patterns of use.
Draws conclusions and makes management plans without fully establishing the basis for diagnosis or current risk (including lack of assessment of previous treatment or comorbidities).
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate:
Explains that methadone initiation must be managed by specialist drug services and outlines reasons for not prescribing today, including patient safety and need for monitoring.
Provides alternative management by referring to the drug and alcohol service, describes what they offer and strongly endorses their support.
Fails to provide appropriate and or safe management choices:
Does not explain why methadone cannot be prescribed in general practice or gives no alternative plan for heroin addiction.
Fails to address the risks of unsupervised prescribing and/or does not clarify how specialist services can support recovery.
Continuity of care is prioritised:
Offers referrals to drug and alcohol services, ensures follow-up through their team, and reaffirms practice contact for further needs or queries.
Documents details for future contact (e.g. phone rather than address) and explains how patient will continue their care journey, promoting ongoing support.
Ongoing care is uncoordinated:
Refers without clear explanation of how care will continue or does not provide a plan for ongoing support.
Omits details on how contact and follow-up will be managed given the patient’s homelessness and changed circumstances.
Empowers self care and independence:
Explicitly encourages harm reduction e.g. using clean needles, attending needle exchange, eating regularly, and seeking support with social and emotional needs.
Normalises struggle and relapse, congratulates patient’s motivation, and provides information on practical steps towards safer drug use.
Management fails to foster self care and patient involvement:
Does not promote safer injecting practices or fails to advise on steps patient can take outside formal healthcare services.
Omits encouragement or involvement, making the patient passive in the process.
Prescribes safely considering local and national guidance:
Applies national guidelines around opioid substitution therapy and controlled drugs.
Refuses on-the-day methadone prescribing in line with safe practice and signposts to services offering structured opioid substitution.
Unsafe prescribing ignoring best practice:
Prescribes or promises methadone inappropriately without necessary assessment, putting patient at risk.
Fails to recognise risks associated with unsupervised or unmonitored opioid substitution treatment.
Refers appropriately being mindful of resource:
Makes timely referrals to both the specialist substance misuse team (CGL) and social prescribers, recognising these are the most suitable resources for complex needs.
Considers the limits of primary care and seeks input from relevant multi-agency teams.
Sends patients for specialist input unnecessarily:
Refers without explaining or justifying the need, or directs to inappropriate teams.
Omits potentially beneficial referrals for social, psychological, or specialist substance misuse input.
Practises holistically, promoting health, and safeguarding:
Explores and addresses social determinants (homelessness, isolation) and signposts to food banks and safe accommodation.
Brings up harm minimisation, mental health, emotional needs, and recognises his vulnerability as an at-risk adult.
Fails to safeguard patient welfare:
Misses exploration of safeguarding issues, such as risk of neglect, violence, or self-harm linked to homelessness and addiction.
Ignores need for harm reduction or broader health and social care.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way:
Responds to Ketan’s distress and motivation to seek help with empathy (“asking for help is not easy”).
Acknowledges the emotional impact of addiction and recent traumatic events, validating his wish to change.
Uses language that encourages trust and engagement throughout the encounter.
Communication is doctor-centred and lacks empathy:
Does not acknowledge Ketan’s distress, trauma, or the difficulty of his situation.
Focuses only on drug history, missing cues about feelings or life circumstances.
Makes the patient feel lectured or dismissed rather than supported.
Treats patients fairly and with respect:
Speaks without judgement about heroin use, stealing, homelessness, and family breakdown.
Displays respect for Ketan’s dignity, despite his vulnerabilities.
Decisions fail to prioritise the patient’s rights and interests:
Communicates in a way that implies blame or discrimination due to addiction or homelessness.
Fails to respect Ketan’s preferences regarding social or referral options.
Explores the patient’s agenda, health beliefs and preferences:
Asks about Ketan’s ideas, motivation, and expectations regarding methadone and recovery.
Investigates the emotional and social consequences of addiction.
Recognises cues about his relationships, family breakdown, and priorities for change.
Fails to recognise the patient’s agenda and impact of the problem:
Ignores or misses cues about what Ketan wants from today or his views on treatment.
Does not consider the effects of addiction on Ketan’s life, relationships, and future goals.
The patient’s agenda was understood:
Clearly elicits concerns about overdose, desire for change, hope for methadone, and lack of safety/support.
Checks what he’s expecting from the consultation and what he hopes from treatment.
The patient’s agenda was not well explored:
Does not clarify Ketan’s goals or concerns, leading to misunderstanding or frustration around management.
Fails to acknowledge his desire for practical help and stability.
Recognises what matters to the patient and works collaboratively to enhance patient care:
Collaborates on practical steps (referral, social support, harm reduction) and offers tailored options for contact.
Responds to cues about family relationships, loneliness, and priorities for housing and safety.
Encourages shared decision-making throughout the interaction
Fails to work with the patient to plan care:
Imposes management without checking what matters to Ketan.
Leaves out discussion about ongoing needs or practical barriers (e.g. no address).
Demonstrates an empathic approach, and a willingness to help and care for the patient:
Offers practical and emotional support, not just signposting.
Praises his motivation and effort, provides encouragement, and checks what else he needs.
Perseveres in offering social support even when Ketan is initially uninterested.
Lacks empathy and fails to recognise emotional cues:
Misses or dismisses sadness, frustration, disappointment (e.g. methadone refusal).
Does not follow up on the emotional or practical impact of being homeless and isolated.
ℹ️ Insights from the examiner
Case at a glance
Ketan is using heroin daily, including injecting, and is sharing needles. He is sofa surfing, has no fixed address, and wants help to stop using drugs. He expects to receive methadone during the consultation.
He is socially vulnerable and may be affected by homelessness, food insecurity, trauma, isolation, strained family relationships and possible mental-health difficulties. The consultation should provide a safe, non-judgemental assessment, address immediate risks, give harm-reduction advice and link him urgently with a specialist drug and alcohol service.
GP trainee performance focus
A strong GP trainee should demonstrate that they can:
What this case is testing
Patient priorities and concerns
Ketan’s priorities may include:
Central challenge
The central challenge is to respond constructively when Ketan expects methadone, while explaining that it is not safe to initiate methadone in primary care without appropriate specialist assessment and monitoring.
The clinician must balance:
Must-not-miss issue or diagnosis
The must-not-miss issues are acute complications of injecting drug use and social vulnerability, including:
Red flags or high-risk features
High-risk features include:
Common GP trainee pitfalls
What good looks like
A strong consultation is respectful, practical and safety-focused. The trainee acknowledges Ketan’s motivation, explains the limits of what can be safely prescribed today, and offers immediate meaningful help.
“I understand why you’re frustrated. It isn’t safe for us to prescribe methadone without the extra support and monitoring, but I want to help you get the right treatment and link you with the specialist team as quickly as possible.”
Learner checkpoint
Have I responded to Ketan’s request for methadone without losing the opportunity to assess risk, reduce harm and arrange urgent support?
Start with an open question
Begin with Ketan’s story and expectations.
“Can you tell me what’s been happening and what you were hoping we could help with today?”
If he directly asks for methadone, explore this without shutting the conversation down.
“I can hear that starting treatment is really important to you. Can I understand a bit more about your drug use and what support you’ve had before, so we can make the safest plan?”
Time-efficient data gathering
Allow Ketan’s story to unfold before moving to targeted questions about immediate risk.
Establish:
Clarify current drug use:
High-yield questions
Drug use and withdrawal
Injecting and harm reduction
Acute physical health
Ask about:
Mental health and safety
Ask about:
Social vulnerability
Ask about:
Functional, psychosocial or contextual assessment
Explore emotional, physical and social consequences.
“How has all of this affected your physical health and your relationships?”
“Has it ever put you in danger?”
Assess:
Explore ideas, concerns and expectations
Ketan’s request for methadone may also represent a wish for safety, stability and support.
“What’s your main hope from today? Is it just starting treatment, or would you also like help with housing or getting back in touch with family?”
Clarify realistic immediate steps:
“We can’t give methadone today, but would introducing you to the team who could, along with more support, be a step in the right direction?”
Possible goals include:
Recognise and respond to cues
Ketan may mention:
If he mentions his friend’s overdose:
“It sounds like your friend’s overdose really shook you. Can you say more about how you felt after that?”
If he mentions a strained relationship with his mother:
“You mentioned losing contact with your mum after borrowing money. Has that been hard for you?”
If he appears embarrassed:
“I can see it’s difficult to talk about this. Thank you for sharing.”
Useful consultation phrases
“You mentioned feeling things have ‘gone to bits’. That sounds really tough.”
“We do want to help. The safest way is to link you with a specialist team who can start you on methadone with the right monitoring.”
“Clean needles reduce the risk of infection. You can get these from a needle-exchange service.”
“The safest way to start methadone is with the expert team. My job is to get you linked with them as quickly as possible.”
“Even making this appointment is a huge start. Let’s set up the next support network.”
Consultation flow and signposting
Useful transition:
“Given what you’ve told me, I want to check a couple more things to make sure we’re not missing anything urgent. Would that be okay?”
Summarising and checking understanding
Summarise the key issues clearly.
“You want help to stop injecting, you’re currently sharing needles and you don’t have a fixed address. You also want treatment today, but the safest route is for us to connect you urgently with the specialist team.”
Check:
Data gathering self-check
Before moving to management, the trainee should know:
Assessment domain mapping
Data gathering
Clinical management
Relating to others
Prioritised differential diagnosis or clinical reasoning
The differential should reflect acute risks, chronic harm and additional diagnoses:
Clinical reasoning script
“My main concerns are your safety, especially with the shared needles and any weight loss or injection problems. I’d like to check for infection and blood-borne viruses, and I want to link you urgently with the specialist team who can start treatment such as methadone safely.”
Red flags and risk assessment
Ask about and examine for:
Arrange urgent medical assessment if there are signs of:
Decision points
Key decisions include:
Management priority
The management priority is to reduce immediate harm and connect Ketan with specialist support quickly.
This includes:
Management options
1. Specialist drug and alcohol referral
Refer Ketan to a drug and alcohol service for:
Methadone and buprenorphine should not be started outside an appropriate specialist setting without the required support and monitoring.
If Ketan expects methadone immediately:
“I recognise that’s your hope, but the safest way — and what is recommended in the guidance and keeps people well — is through specialist support. I can help get that started right away.”
2. Needle-exchange service
Offer referral to a needle-exchange service so Ketan can access:
Explain that using clean equipment reduces the risk of blood-borne viruses and injection-related infection.
3. Blood-borne virus screening and vaccination
Offer screening for:
Offer vaccination where appropriate, particularly for hepatitis B.
Discuss sexual health assessment where relevant, including:
4. Physical-health assessment
Arrange assessment for:
5. Mental-health support
Assess for:
Offer mental-health support and urgent intervention if there is immediate risk.
6. Housing and welfare support
Refer to social prescribing or relevant local services for:
7. Fit note or sick note
Offer a fit note if Ketan is undertaking casual work and his health or treatment engagement affects his ability to work.
This should be linked to a wider support plan rather than being the only intervention.
8. Nutrition support
Offer:
9. Family involvement
Explore whether Ketan would like family involved.
This may include:
Do not impose family involvement if it is unwanted or unsafe.
Personalised plan
Tailor the plan to Ketan’s social circumstances.
Example:
“Because you don’t have a fixed address, I’ll make sure the team know to contact you by phone, and you can collect any information directly from the practice.”
If he is open to help:
“Our social prescriber may be able to help you find safe accommodation now. With winter coming on, that’s important.”
Recognise his motivation:
“Your motivation is strong — hold onto that. Even with setbacks, we’ll carry on working with you.”
A personalised plan should include:
Shared decision-making
Check Ketan’s agreement and engagement at each major step.
“Does that make sense?”
“How do you feel about the plan to see the drug and alcohol team and get support with housing?”
“Is there anything in this plan that worries you, or anything you’d like more information about?”
Explore which steps feel most achievable today.
Safety-netting
Explain when and how to seek help for:
Make sure Ketan knows how to access urgent help and what to do if he misses appointments.
Ethical, legal and safeguarding considerations
homelessness, substance use and social vulnerability should trigger careful consideration of safeguarding and exploitation risks.
Key principles:
Documentation points
Document:
Common unsafe management plans
Avoid:
Follow-up and coordination with other professionals
Coordinate care with:
Follow-up should account for no fixed address by clarifying:
Learner checkpoint
Have I made an immediate harm-reduction plan and a realistic follow-up plan that works despite Ketan’s homelessness?
Relevant guidance areas
NICE guidance
BNF references
GMC, DVLA or safeguarding guidance
This includes:
RCGP and SCA resources
Relevant research or educational references
Practical support resources mentioned
Key principles to remember
Transferable learning for future cases
In consultations about substance dependence and social vulnerability:
Supervisor or examiner lens
A supervisor or examiner is likely to look for:
Final learner takeaway
When heroin dependence and homelessness coexist, the GP role is to reduce immediate harm, assess acute risk, and connect the patient rapidly with specialist and social support — without judgement.
