‘My greatest worry about my review and its potential is can we deliver it at the local level,’ Professor Dame Carol Black told the Westminster Social Policy Forum’s Tackling drug dependence and improving delivery of services seminar.
‘We’ve acquired the investment – that was of course crucial, but there must be much greater accountability for the spend.’
The Treasury fully intended to ‘hold us to account’, she stated, echoing warnings from others in the field (DDN, February, page 8). Local authorities would need to work with wider health, employment, housing support, criminal justice and social care, and develop joint commissioning plans and joint needs assessments. Years of austerity had meant that the idea of creating a whole systems-approach ‘wasn’t able to happen’, she said, ‘and what I’m hoping from my review is that we’ll now be able to do that, because it’s absolutely needed.’ This would require at least six departments of state to be ‘truly and sustainably involved’, she said. While it ‘wasn’t that they hadn’t been interested before’, competing priorities meant that it had always been low on their agenda.
All but one of the 32 recommendations in her Review of drugs: phase two report had been taken on board in the government’s new drug strategy, which was ‘very pleasing’ – and accompanied by a financial settlement that was ‘probably 70 per cent of what I’d asked for in the original part two review’ and ‘very big’ ambition. ‘But I don’t want, now that we’ve got more money, to just do more of the same,’ she stated. ‘This is a unique opportunity to really think about what does a very good treatment and recovery service look like.’
Starting from a low base
It was important to be aware that in some places ‘we’re starting from a low base, and we’ll need to support and enable improvement in some of our local areas,’ she said. The sector was facing a challenging journey, not least in terms of re-building the workforce. ‘That’s going to require a really sustained focus – we can’t just do it overnight.’ Similarly, research had been ‘bottom of the pile’ in almost every aspect of addiction, with a corresponding lack of financial support.
Workforce was a ‘critical challenge’, agreed head of inclusion at Midlands Partnership NHS Foundation Trust, Danny Hames. There was promising evidence of positive cross-sector working, but providers needed to be ‘brave and a bit humble’, he said. ‘We need to open ourselves up to accountability and be transparent, but we also need to be sure we’re working in the best interests of patients. Collaboration is absolutely key.’
Moving forward
‘We’re at the point where we have to look at the competence of our own clinical practices and commissioning process so we can move the field forward,’ said head of King’s College London’s National Addiction Centre, Professor Sir John Strang. One of the major challenges would be improving the quality – as well as the quantity – of treatment, and there was a significant challenge around training need. ‘We need to look at how to support and improve the development of the general workforce, so that somebody entering treatment is being seen by someone with a good, broad knowledge of the treatment field and how to integrate medical and social interventions,’ along with developing a cadre of specialists for the future.
From a research point of view, what was needed was a serious commitment to a much more practice and policy-orientated research agenda, he said. ‘If you look at the National Institute on Drug Abuse in the US, we don’t have anything comparable – which means we don’t have that critical science perspective.’
While the strategy committed to building a world-leading evidence base there was no mention of consumption rooms, said Release executive director Niamh Eastwood, despite evidence of their effectiveness and ability to provide access to treatment and other support. The strategy was a ‘tale of two competing directions’, with ‘once again an over-focus on criminal justice responses’ – something that undermined the ambition to get people into treatment. ‘When we treat people first and foremost as criminals, it’s very hard to address their health needs.’
The evidence base
‘We’re traditionally seen as the enforcers,’ deputy chief constable of Lincolnshire Police, Jason Harwin, told the seminar. ‘And let’s be very clear, we have significant numbers of serious organised criminals who are exploiting young and vulnerable people, who we have to continue to enforce the law against. But we do need to make sure we’re diverting individuals to effective, evidence-based treatment services that we know reduces their vulnerability and their likelihood to continue to commit offences.’
‘From my own experience of addiction I’ve lived a definition of madness, which is doing the same thing over and over again and expecting a different result,’ said the Scottish Recovery Consortium’s lived experience officer, Michaela Jones. ‘The only solution in these circumstances is to stop and recognise the need for radical and sustained change – in this case it’s to accept that the resilience and flexibility of the drugs market make it almost impervious to enforcement activity.’
There had in fact been extensive, informal decriminalisation, said Strang. ‘It’s not been driven by laws, it’s driven by changing attitudes within different police forces and within society, and that’s a much more important level at which to engage.’
Deprivation
In terms of preventing dependency, Release had consistently argued for re-allocating some of the ‘endless resources’ for law enforcement into trauma-informed counselling in schools from an early age, said Eastwood. ‘We know adverse childhood experiences are one of the biggest drivers for drug dependency. That could have a massive impact – addiction isn’t all about the drugs, it’s very much a response to abuse, neglect, deprivation.’
Market forces
Legal and illegal drug markets went ‘back and forth’, said Dr Keith Humphreys, professor of psychiatry at Stanford University, advisor to the Carol Black review and former drug policy advisor to President Obama. ‘It was legal companies that flooded our healthcare system with a 400 per cent increase in per capita prescribing, and many, many people got addicted to those drugs. Heroin traffickers then realised “there’s gold in them thar hills”, started to expand to different cities and began getting as customers people who were addicted to legal drugs like oxycontin.
‘If you believe that full legalisation, as is commonly said, will only bring good things then you have to be candid about what we’ve learned about the legal drugs we have’, he continued, as tobacco and alcohol killed far more than all illegal drugs combined. ‘If you’re going to argue – as many bright people have – that we should have corporations like the tobacco industry sell methamphetamine and cocaine, you should explain why those drugs wouldn’t then be up there at the top of that list.’
Reducing demand
In terms of reducing demand, while it was possible to use the media to encourage people to access services or give them factual information, advertising campaigns to discourage drug use simply didn’t work, he said. ‘Demand responds to supply, as is well demonstrated across all kinds of industries. Within the prescription system, where we at least putatively have a huge amount of control, if we don’t exercise that wisely we’ll get a lot more demand as we’ll make many more people dependent on – in the US and Canada – opioids, but also benzodiazepines, stimulant medication and so on.’
Ultimately, putting the person at the centre of services was vital, stressed Black. ‘We would do that with any other condition, and this really is a chronic disease with remissions and relapses. The real issue for me now is how do we keep this energy up, and enable it to go forward, keeping the government’s foot on the peddle and making sure it really is a whole-systems approach. We really have the opportunity to improve a quite dire situation when it comes to treatment and recovery. There’s a willingness to think about doing things differently. But everyone also recognises the hill that needs to be climbed.’
Landmark opportunity
‘This is a landmark opportunity for a system transformation that will help us save lives and improve outcomes for individuals and the communities in which they live,’ said Rosanna O’Connor, director of addictions and inclusion at the Office for Health Improvement and Disparities (OHID). ‘It’s a very significant moment.’ It was also important to put aside concerns about the criminal justice focus, she said. ‘It’s through the criminal justice lens that we’ve landed ourselves such significant investment in treatment and recovery.
‘It’s surprising to find myself on a platform saying the politicians have delivered, and it’s now in our hands as a sector. We have to collaborate to deliver, and really up our game across the whole system if we’re to have any chance of having this investment sustained. We can do it, but we have to do it together.’