At an event organised by the London Drug and Alcohol Policy Forum, the challenge of not losing sight of the individual in the new public health landscape emerged as a prevalent theme.
‘We were created as a response to what was a frankly appalling drug and alcohol treatment system in Sunderland,’ CEO of Counted 4, John Devitt, told delegates at the London Drug and Alcohol Policy Forum’s recent Our friends in the north event. ‘There were six- to nine-month waiting lists and very rigid prescribing regimes. We were set up to serve the people of Sunderland – it’s about treating people in the community in the normal way, without ghettoising them.’
A clinically led organisation and community interest company (CIC), Counted 4 employed doctors, nurses and drug workers, and provided a range of services in the home. It also tried to work in partnership with key providers, such as pharmacies, he said, and aimed to be client-focused, non-judgmental, accessible and community-based.
‘We’re living in a very interesting world – it’s a time of huge social change,’ he said, with welfare reform, funding cuts and the move to Public Health England all having an impact. While there had been positive changes – such as the focus on recovery – the poor were now being widely demonised, he stressed, which was having a profound effect on vulnerable people.
Sharing an ethos
Treatment staff were also worried about their job security, he said. ‘But the real question is who’s worrying about the clients? It’s also a unique situation in that the main political parties seem to agree on pretty much everything when it comes to these changes, and many charities are just toeing the line. Everybody talks about working in partnership, but partnership is about sharing an ethos, sharing working practices, sharing the good and bad times. Everyone’s going to have to move much more in that direction because we’re going to have to make the most of the resources we’ve got in the community.
‘The key thing is to stop bringing people into services,’ said the organisation’s recovery and tier 4 lead, Brian Hindmarch. ‘Take the services into the community.’
One of the biggest problems facing treatment was translating its founding vision across the workforce and to partner organisations, said Counted 4’s medical director, Dr Martin Weatherhead. ‘We can often say, “for this group of people we provide a fabulous service”, but I’ve not really come across a system that provides that across the board.’
While there had been no major change in the evidence base, there had been changes in the interpretation of that evidence base, he continued. ‘What we’re guilty of is extrapolation – there have been changes in emphasis, but no huge changes in fact.’
Keyworking was vital, he told the event. ‘Prescribing is just a little bit of oil in the engine of treatment – you can’t build everything around that. The medication hasn’t changed, the facts haven’t changed, but everyone’s now terrified of being seen as “parking” people on methadone. But there are people who need those higher doses. We’re moving back into a more regimented treatment world, and that does concern me.’
One problem that treatment needed to overcome was that NICE guidelines were constantly employed as obstacles, said one delegate. ‘If they don’t want to do something, or if they do, then you hear, “ah, it’s the guidelines”.’
‘As an industry, our customers aren’t our first priority,’ said another participant. ‘The drug treatment system has been awash with money for years, but no one ever says that everything’s working well.’ However it was impossible to commission ‘perfectly individualised’ services for everyone, replied another. ‘It’s a pipe dream. What you can do is get what’s best for that individual at that time, because it changes over time – people change, systems change, money flows change. You need flexible services that are responsive. A lot of it is about relationship management and being human – it’s a patchwork.’
While the recovery agenda contained a great deal of pros and cons, ‘one positive thing to come out of it is to try to get the best for your clients,’ commented another delegate. ‘But changing the ethos of an organisation can be like turning a tanker.’
‘Get to know the client,’ stressed one participant. ‘On paper they may look like one thing, but you need to get to know them. And continuity is vital.’ Having the right people with the correct skills set was vital, added another. ‘The right person for the right role.’
An obvious problem facing the sector was that budgets were no longer ring-fenced, a delegate stressed. ‘So we need to show that the things we commission are meeting what they’re supposed to. Ultimately it comes down to whether we’ll continue to be funded – and if the service is cut, that doesn’t meet anyone’s needs’, while others commented that disinvestment was already happening.
There were also significant problems around recruiting specialist GPs, Martin Weatherhead told the event. ‘The areas where you have the most problems recruiting doctors are deprived areas. Doctors are herd animals – they’ll go where the herd is grazing. There’s a huge recruitment crisis in general practice – the GPs who are working are overwhelmed and the last thing they want to do is make their lives even more difficult by working with people with substance problems.’
Risk was often used as an excuse not to act, commented one delegate. ‘Senior politicians need to have the ability to trust people to deliver, so they can prove the impact. You’ve got to protect your funding streams, but there’s no trust that things will actually be delivered. There’s got to be a better way than just telling us to tick boxes.’
‘You have to bring hope and aspiration into it,’ said John Devitt. ‘If you can’t do that – because you’ve had a crap day or whatever – then you’re messing with people’s lives and you shouldn’t be in this profession. We’re defining people by their symptoms, so you’re not designing the system for individuals. The key is personalisation – you’re providing a service here. It’s a privilege to be looking after these clients, and if you really believe that you’ll get the results.’