Catch them early

This year’s SMMGP and RCGP conference brought GPs, frontline workers, commissioners and service users together to explore the topics of prevention and early intervention in the new public health environment

Early intervention was the theme at SMMGP and RCGP’s 19th national conference on managing drug and alcohol problems in primary care, promoting an idea of ‘working with the system’ to engage vulnerable people and stop problems before they had a chance to develop. With the backdrop of a changing sector and funding cuts, delegates heard examples of what was happening up and down the country to meet the needs of those affected by drug and alcohol problems, as well as bringing into sharp focus several barriers – both political and social – to taking early action.

The DrugAware model, introduced by programme lead Anna Power, showed education as a means of reaching young people in schools and academies across Nottingham. Power pointed out that young people were seven times more likely to become a drug user if one of their parents were, and so the scheme was aimed at identifying those vulnerable children and engaging with them before problems could take root. It included young people in the development of the in-school programmes, taking the emphasis away from punishment and focusing on engagement. The programme had proved successful, she said, with 80 per cent of schools across Nottingham now DrugAware schools.

‘Change the late intervention culture’ urged Graham Allen, MP for Nottingham North. It was of utmost importance to break the cycle of intergenerational use – and the most effective way of doing this, he said, was by making sure that services and programmes ‘meshed together’, ensuring commissioners and practitioners shared a common goal. Giving children social and emotional support would set them up to have a better standard of life – and early intervention would create an ‘emotional bedrock’ for them.

Allen also pointed out the importance of having a strong evidence base in order to ‘monetise outcomes to get funding’. The best way to appeal to the government and policymakers, he said, was to emphasise the ‘massive cost of failure’, which would inevitably cause more money to be dedicated to drug and alcohol misuse programmes and social welfare.

Duncan Selbie told delegates that preparing children for life was a target for PHE – as it should be for the nation as a whole – not only by dealing with drug and alcohol problems, but also issues like obesity, domestic violence and tobacco. There were ‘three people in the early intervention relationship’ he said – government, local services and the public – and there needed to be a conversation as a nation on how best to tackle these issues. 

When answering questions from the floor, Selbie denied being ‘too cosy’ with the drinks industry, reiterating that PHE was clear in wanting minimum unit pricing and plain tobacco packaging, and saying that ‘being independent isn’t about being loud, it’s about winning.’

Concerns were raised about the state of com­mis­s­ioning, and the effect it was having on delivering a good service. Selbie said that local government ‘understandably wanted the most they could get out of their spending’. He urged services to ‘have the courage and patience to work with that process’ by showing local government that their way of doing things would be the best and give the most value for money.

The effect of the commissioning process on early intervention was touched upon again in a workshop held by Turning Point’s Selina Douglas. She highlighted the challenge that substance misuse services had, more than any other, to make sure they met performance expectations, while under the pressure of ‘having to do more for less’ and keeping service users ‘at the heart of any change’.

Discussion among the workshop participants revealed that the process of tendering and retendering was putting stress on frontline workers, who questioned whether those who were making the changes really understood what it was like, both for them and their service users. The performance focus changed too frequently, said an attendee – where it was once ‘get [service users] in and keep them in’, the focus was now ‘get them out and keep them out’.

Another delegate questioned how the targets that had been set for treatment services were being monitored for long-term effects, and what impact they would have on early intervention and on society ten years down the line. Douglas said that early intervention had been difficult in the past because of a lack of evidence, but that the evidence base was now stronger, which would make it easier in the future.

Di Wright, of the commissioned services for Kent County Council, said that commissioners were looking at commissioning different services together ‘so that it enhances both sides and gets a better service for clients,’ to which Douglas added ‘a substance misuse service cannot exist in isolation – it has to exist in a network of services.’

Stigma and mental health issues also posed obstacles to identifying problems early. Alcohol misuse was an issue that was often overlooked, said consultant liaison psychiatrist Dr Peter Byrne, and many people were reluctant to admit that they were struggling with alcohol for a variety of reasons. Not only was there social stigma, but people with alcohol problems were often seen as ‘the patients that doctors dislike’, said Byrne, and fear that their doctor would treat them differently often prevented people from seeking help. This ‘failure to disclose’ meant problems were not being identified early enough, and community-specific services – such as LGBT and Muslim alcohol services – were needed to help engage with those who were reticent to seek help.

‘Interventions are critical,’ said health improvement lead Lee Knifton, ‘but without relieving social stigma, they won’t be as effective as they can be.’ He told delegates that in Scotland, and in particular Glasgow, overall public health was ‘as bad as it gets’, and had been declining systematically since the ’50s, with health inequalities having accelerated since the ’80s. Almost all of the inequalities, he said, had to do with ‘addiction, mental health, violence and suicide’ and working with these interlinked areas of public health should be a priority.  

Stigma was a complex social phenomenon that ‘dehumanised and separated’, he said, compounded by things like religion, personal experience and the media, and it would take more than just giving people ‘the right information in the right ways’ to tackle it. Ten years ago, Knifton and colleagues in Glasgow mental health services made a ‘city alliance’ with the government and regeneration agencies, which undertook participatory research  studies with marginalised communities who had experienced stigma and discrimination. It aimed to generate practical solutions and brought together a community of organisations alongside service users to understand the nature of stigma and mental health, identifying issues such as a high degree of ‘recovery pessimism’ among practitioners.

As a result of this research, the Scottish Mental Health Arts Festival – now in its eighth year with 200 partner organisations – was created as a means of ‘challenging stigma and perceptions of people experiencing mental health problems’ and engaging harder to reach members of the community, such as the poor and ethnic minorities, through music, art and comedy. The events aimed to start the right sort of discussion about mental health and addiction, with a view to relieving stigma and helping identify problems early.

Changing opinions about early intervention was crucial, added Dr Peter Byrne during a Q&A session, and as a lot of media coverage of mental health and addiction was negative, it was important to publicise stories that would ‘capture the media’s attention’. Among frustrations with the changing commissioning landscape, minimum unit pricing and plain tobacco packaging, it was incredibly difficult to get health into the political debate, but ‘as physicians we need to get the right stories out there,’ he said.

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