Among the now-familiar talk of emerging challenges and stretched resources, delegates at DrugScope’s recent conference heard some positive takes on the new treatment landscape.
‘Whatever views people take of the pros and cons of the times we’re in, what everyone can agree on is we’re charting very new waters in turbulent seas,’ DrugScope’s policy director (now newly appointed chief executive) Marcus Roberts told delegates at the organisation’s Game on: drug and alcohol services and the new local players event.
Localism presented some significant positives and opportunities alongside the challenges, he said. Although the 2010 drug strategy was still setting a direction for services, many of the decisions that affected them were now made at local level, with a loosening of central control and the national drive to focus on crime reduction gone, ‘or at least fading to grey’. The pooled treatment budget, however, had been ‘swept into a bigger public health budget with no meaningful protection, or at least none that anyone can explain or understand’, and there was now a need to convince local partners who may have previously had no engagement with the sector.
‘Obviously, it’s also a case of localism plus tight money and further cuts on the way,’ he said, against a backdrop of the rise of new psychoactive substances and, ‘absolutely critically, the role of alcohol’. But the generic ‘problem drug user’ had always been something of a cipher, he told the conference, and there was now much more meaningful work around specific groups like the LGBT community, women involved in prostitution and older people.
Financially, it was difficult to get a clear grip on what was happening, he said, although DrugScope research had found more than a third of services reporting a decrease in funding (including 10 per cent where it was the result of re-commissioning), 44 per cent reporting a decrease in frontline staff and 63 per cent an increase in the use of volunteers. More than 40 per cent also said they’d so far had no engagement with their local health and wellbeing board.
‘Overall the findings have been suggestive, but not seismic, and they do point to some positives of good adaption and resilience. But it’s worth emphasising that there are significant prima facie risks of disinvestment, and adapting to that may mean further rethinking and reconfiguration.’ The crunch points could well come next April or the April after, he said, as many contracts would have rolled over into this financial year and new structures were still bedding in.
‘I’d underestimated how long it would take for some of our systems to embed,’ echoed director of public health for Barnet and Harrow councils, Dr Andrew Howe. Although there was an austerity agenda and a now-unprotected substance misuse budget, he was ‘not hearing about any substantial disinvestment’, he told delegates. ‘But the challenge to local government is that the savings are to criminal justice and the NHS rather than them, and commissioning is fragmented.’
However, local government did fit very well with the aims of the field in that ‘if it’s about anything, it’s about improving social capital’, he said. ‘I absolutely recognise that we’re building on enormous success in the substance misuse sector, particularly around service user involvement – it’s an exemplar of success for other services – and as a commissioner I’ll be looking for outreach services from our service providers. I’m hoping that the new system will really help with integration.’
The advent of police and crime commissioners (PCCs) had also created uncertainty, said deputy PCC for the South Wales Police, Sophie Howe. PCCs needed to balance budgets and maintain services that local communities cared about, while working to develop partnerships such as the Drug Interventions Programme (DIP) – something that combined harm reduction and reducing reoffending and showed the two could complement each other. ‘But evidence of effectiveness isn’t enough in the current financial climate,’ she said.
‘The coming years are going to get more difficult,’ CEO of Blenheim CDP John Jolly told the conference. ‘I’m still mourning the death of the NTA – I think that’s a huge downside for our sector because we don’t have a body representing us at national government level.’
The NTA had done some excellent work around service user involvement, said chief executive of Build on Belief, Tim Sampey. ‘The change to Public Health England and the tightening of purse strings is a real pity, and re-tendering is awful – it’s dog eat dog and service users hate it. The buildings change, staff change – stability is really important for trust and building relationships, and without it the risk is that people drop out of treatment.’
The recovery agenda was also ‘an awful idea’, he added, and had made service users panic. ‘When I was using I hated the expression “clean”, and there’s something about recovery that seems a bit judgemental – whether it’s true or not, it’s the perception that service users have.’ Nonetheless, mutual aid could well be the future, he said. ‘I’ve seen some great stuff around mutual aid, and I don’t mean the 12-step stuff. What we need is community and family and somewhere to belong – if we can do that we can really help people.’
The ‘elephant in the room’, however, was the underfunding of, and unmet need for, alcohol services, said John Jolly. ‘There’s been a u-turn on almost everything in the alcohol strategy, and the resources that are already stretched are going to become even more stretched, with the risk that alcohol need is going to hugely reduce our capacity to deliver to other groups.’
There was also the challenge of new drugs, he said, with many users reluctant to access services and receiving no support. ‘So it’s about how we make our services relevant to specific groups such as older alcohol users and young people using new psychoactive substances – you have to give them something relevant or they won’t come. They need to like what’s on offer and like the people there.’ In the current commissioning environment, however, there was huge unmet need and ‘the risk of not being able to meet any of it’.
‘Yes, the funding has changed and there are competing priorities in local authorities for all their resources and for the public health grant, and I’m well aware that there’s widespread redesign and retendering,’ Public Health England’s director of alcohol and drugs, Rosanna O’Connor, told the conference. However, there were fewer adults in treatment than ever, she said (see news story, page 4), and the number of people starting new treatment journeys had also gone down.
‘Cannabis is the only primary-presenting drug that has any kind of increase and there are now more non-opiate clients than opiate clients,’ she stated. However, there were still increasing numbers of over-40s coming into treatment for the first time and the number of successful completions had ‘pretty much plateaued’.
‘The existing health gains and recovery ambition need to be maintained and strengthened, the sector needs to be championed and strategic partners engaged,’ she said. ‘You must ask for the investment you need. We do expect for there to be appropriate local services and for them to be properly invested in. The task in terms of making sure every service user gets a half-decent chance of successfully completing treatment is not the same across the country, and that’s not good enough.’ PHE was offering enhanced support to more than 40 local authorities that were performing less well, she stressed.
The political interest in the sector was there, she emphasised, as recovery continued to be a key measure in national outcome indicators, closely monitored by ministers and PHE. Drugs recovery would also be priority indicator of the government’s proposed ‘health premium’ if it went ahead, she said.
Particular challenges were the number of entrenched heroin users, for whom lasting recovery was often much harder to achieve, and the emergence of new psychoactive substances at an ‘unprecedented’ rate. Although the number of people seeking treatment for the latter remained small, ‘the ability of all of us to keep abreast of this is a challenge’, she said. Mephedrone presentations had almost doubled in the last year but should be seen against falling numbers of people seeking treatment for ecstasy, she added.
‘What on earth do we call these things?’ said toxicologist at St George’s Hospital medical school, John Ramsey, of the new drugs. ‘New psychoactive substances doesn’t really trip off the tongue, and legal highs doesn’t work either so I choose to call them new and emerging drugs of abuse.’ The new compounds fell outside legislation with the consequences that people were being exposed to an ‘ever-changing list’ of chemicals. ‘What do we do? If kids are having medical problems then you can’t ignore it, but when you ban them you just get a whole lot of new ones.’
‘There are genuine opportunities with Public Health England,’ said outgoing DrugScope chief executive Martin Barnes, as he summed up both the event and his ten years at the organisation. ‘But despite genuine high-level commitment to drug treatment and recovery, the government has created a situation where funding is at risk. Whatever your view of the NTA, it was effective at holding DAATs and providers to account. The pendulum of localism may swing back, but at the moment what ministers think is increasingly less important.’
Further local government perspective came from cabinet member for health and wellbeing at Birmingham City Council, Steve Bedser. ‘There is a huge risk of disinvestment,’ he acknowledged. ‘“Severe” is an understatement when it comes to the pressures on local authorities, and we are, of necessity, looking at the commissioning portfolios and practices we’ve inherited. Some of the services we’ve inherited have been very poorly commissioned indeed. We have to make sense of the money and find interventions that are cost-effective. We face hard choices on the use of public money and you will have to work hard to engage politicians.
‘But if there’s a sliver of a silver lining in the whole austerity agenda, it’s that it does give us an opportunity to do integration properly. Have faith in health and wellbeing boards. They’re good things, so make sure you influence them.’