The drug and alcohol treatment sector was in a period of profound change, DrugScope’s director of policy, Marcus Roberts, told delegates at the organisation’s A question of balance: delivering an inclusive treatment and recovery system conference. DrugScope had been broadly supportive of the notion of ‘recovery’, he said, in terms of individually-focused journeys and community support, ‘but I wonder if the high tide of recovery as an organising definition for our times has already been passed, as we find ourselves in this new environment’.
Issues of crime prevention were already moving rapidly up the agenda, he told the conference. ‘While that’s certainly a lever for investment, how does it balance with the more positive message of recovery?’ The sector was now in a position of having to ‘talk to different audiences’ locally – directors of public health and police and crime commissioners – and there was also the question of how the vision of recovery set out in the Drug strategy 2010 translated into local action. ‘The broader message from government is that it’s not in the business of providing guidance, as that goes against localism.’
Many decisions would now be made in town halls, he said, and while several of the functions of the NTA might live on in Public Health England (PHE), most of the money would go to directors of public health. ‘Responsibility for treatment systems, and the chronic and acute health issues of drug and alcohol problems, are passing from the NHS to local authorities, which raises crucial questions around clinical governance. If this was happening with diabetes or mental health, for example, I think we’d be hearing a lot more about it.’
The national policy debate was still very much focused on problem drug users, he continued, particularly those dependent on heroin, despite the numbers of 18 to 24-year-olds needing treatment for class A drugs falling dramatically (DDN, November, page 5). The sector was increasingly working with people who had problems with other kinds of substances, he said – skunk, GBL, ketamine and alcohol – as well as particular populations like the LGBT community and victims of domestic violence. ‘At a policy level I just don’t think we’re grasping the potential for a qualitative shift. That’s not to suggest we lose the focus on the problem drug users who often have the most entrenched needs, but move to a broader scope that speaks more to the public health environment. We’re in a period where careful navigation will be needed.’
Although April 2013 had come to assume the status of a ‘canonical date’ in the sector, it was very likely that many changes would ‘start to bite’ later, he said, for example when police and crime commissioners took responsibility for spending Drug Intervention Programme (DIP) funding. ‘It’s important that you don’t drop your guard,’ he told delegates. The ‘constant talk’ – by vested interests – that drug policy was failing was also potentially damaging, he stressed. ‘It’s not true. But if you’re a new commissioner, for example, that’s going to be influencing your views. We need to get out and make the case locally.’
While approaches to treatment did need to adapt to changing needs, said public health minister Anna Soubry, ‘we are making inroads and there’s much to be proud of. If someone wanted to stop using drugs ten years ago they’d have had to wait weeks – now it’s five days. Although I don’t like jargon, we’ve got to work together to make sure recovery is what it says in the drug strategy – an “individual, people-centred journey”.’
The government wanted to see more people abstinent and leading productive lives, she stated. ‘I don’t apologise for that, but I do recognise the role methadone can play in some people’s lives.’ While there would be ‘few that would disagree’ that methadone had been inappropriately used – with people ‘parked’ on the substitute medication – the government had endorsed the Medications in recovery report by Professor John Strang’s expert group (DDN, August, page 5) and there was agreement ‘across government’ about the role of methadone in treatment.
On the subject of payment by results (PbR), she had met with representatives of the eight pilot areas and been ‘blown away’, she told the conference. ‘I’m not saying there aren’t difficulties, but there was a real enthusiasm for the work they were doing.’ The government intended to learn from the pilots, she said, including how to improve and coordinate support from housing, education and criminal justice departments. Questioned on whether PbR would be rolled out across the country, she said that the government ‘genuinely’ had an open mind. ‘If it’s going to be rolled out, we have to do it properly and it has to be properly modelled. It’s still early days. It’s not an ideological matter – I’m not saying “we’re only going to do payment by results”. We’re going to do what’s best, but, so far, so good.’
The issue was balancing a more aspirational approach with ‘some caution’, so that what people were expected to achieve was realistic, said Professor Strang, head of King’s College London’s addictions department. ‘We’ve been inappropriately preoccupied with retention in treatment per se, and my worry is that we’ll now move on to just focusing on exit from treatment without considering the benefit from treatment.’
He was concerned about people reading things into the drug strategy that weren’t there, he said. ‘Retention in treatment is not recovery, and neither is abstinence – it might be part of how you achieve it. There will be times when medication helps with recovery, or is even crucial to it, and times when it will be irrelevant.’
This was not an issue unique to substance misuse, he continued. ‘In mental health, there are occasions when medication is appropriate and occasions when it’s inappropriate. We need to do a lot more thinking about this – if there are exciting things coming down the line like vaccinations to neutralise the effects of cocaine, for example, or long-lasting versions of buprenorphine, then how do these fit in? We need to be skilled practitioners in knowing what’s right for people.’ It was about ‘moving towards something more aspirational’, he stressed. ‘But you can’t just encourage people to go down that riskier aspirational pathway without knowing how you’ll deal with it if it doesn’t work out.
‘In my view we have a lot of substandard treatment in this country,’ he told delegates. ‘The intensity and quality of the support we provide is not as good as it could be, or as in other countries.’ Part of the reason was ‘institutional inertia’, he said, as well as an ‘obscene pursuit’ of cheapness. ‘Value for money is what purchasers should be pursuing, not cheapness. It’s a challenging call.’
On the question of whether NHS services were needed in the new landscape, strategic director of addiction and offender care for CNWL NHS Foundation Trust, Annette Dale-Perera, told the conference that the NHS was no longer a single entity but rather a range of commissioning groups and provider bodies. A survey of tenders and retendering carried out by the Royal College of Psychiatrists had found that ‘if you’re the provider you’re less likely to win than a new organisation – the grass is always greener – and you’re even less likely to win if you’re an NHS incumbent’, she said. NHS organisations tended to be more expensive, and there was also a perception that they were not ‘recovery-focused’ enough and too slow to change. ‘So it’s an ever-shrinking number of NHS providers and we’re losing that skill set, losing NHS staff trained in addiction.’
The result, combined with the ongoing split between drug and alcohol treatment, was that the sector was failing to ‘future-proof’ itself. ‘The rhetoric coming out centrally is that drug use is down, but I think seeing drugs as separate from alcohol is becoming more and more outmoded,’ she said, with a 40 per cent increase in primary diagnosis alcohol-related hospital admissions since 2002/03.
‘Substance use is not necessarily going down if you look at the whole picture, and we have to provide culturally appropriate services to address that. The people who come through our doors are poly-substance users, and that includes alcohol. If you look at the figures, methadone use is up, along with methamphetamine, ketamine, GBL and GHB, BZP, Spice and mephedrone – we’ve seen young people who’ve been on mephedrone binges having two-day psychotic episodes. And those are just the drugs they measure – the British Crime Survey, the school surveys and so on, don’t measure a lot of the stuff that’s being used.’
The move to public health meant a policy shift towards behaviour change at population level, she said, ‘so there’s a whole new language to be learned, and the NHS needs to be involved. If we ignore that, we do so at our peril.’
The residential rehab sector, meanwhile, was facing its own particular challenges, said Phoenix Futures chief executive Karen Biggs, including an ageing treatment population, increased running costs and reductions in both public spending and average lengths of stay. While residential services were more expensive than others, this didn’t mean they were less value for money, she stressed, and alongside the challenges of evidencing outcomes and PbR, specialist services could ‘really struggle’ within a localism framework.
‘When we look at the value for money argument, the easiest case to make is that residential services provide the expertise and experience to address really entrenched problems,’ she told delegates. ‘We also need to be able to map our services to provide better matching of clients and evidence the wider “recovery agenda” work we do. We’re not a homogenous group – we deliver very different types of services, and I think we’re at a time when we can think of residential services as part of an integrated system.’
The programme offered by the Ley Community in Oxfordshire was a year long and highly structured, in a ‘safe and enabling environment’, said its chief executive Wendy Dawson. ‘But increasingly I have commissioners saying “can I just purchase an aspect of your intervention?” Well no, because it’s a progression. We don’t just deal with drugs and alcohol. We deal with issues, and support residents to learn new skills.’
Just 0.55 per cent of people requiring treatment in the NHS system got a residential place, said Nelson Trust chief executive Steve Cooke, with a quarter of residential treatment centres closing between 2003 and 2010. ‘Not everybody needs residential rehab. There are fantastic prescribing services – very few are just dishing out methadone like in the old days – but the sad fact is that residential treatment centres are closing, and when people are in residential they get the time and space to build relationships, build a therapeutic alliance and address the issues that got them there in the first place.’
What mattered ultimately was evidence, UKDPC chief executive Roger Howard told the conference. ‘We’ve spent an awful lot of time beating ourselves up in this sector. If there’s one DNA thread running through our Fresh approach to drugs report (DDN, November, page 4) it’s the importance of evidence. We don’t evidence properly – many programmes are not evaluated.’
One of the biggest obstacles was cultural, he stressed. ‘We struggle against the killer anecdote – “my mate got off drugs this way”, or “this is how it was done in this place, so this is how it should be done everywhere”. Policy and practice needed to be evidence-imbued rather than evidence-based or informed, he said, with negative evidence seen as learning rather than failure.
It was also vital to extend the debate into the broader social policy arena and issues of inequality, he said, with Child Poverty Action Group chief executive Alison Garnham telling delegates that her organisation had ‘a serious problem with the current narrative about how we tackle poverty’, such as the troubled families agenda. ‘These are not the “neighbours from hell”. We have to respond to the urgent circumstances of the children affected by parental drug and alcohol misuse, but we need to respond to that and not the rhetoric.’
Although the sector was undoubtedly going through very challenging times, it had ‘never shirked a challenge’, DrugScope chief executive Martin Barnes told the conference. ‘We do have the passion, savvy and maturity to respond. We’ve just got to hold our nerve.’
‘There’s a duty on all of us to demonstrate value for money to taxpayers in austere times,’ said Roger Howard. ‘But it’s even more important to deliver the optimal care.’ DDN