How can we refocus drug and alcohol services on competent compassion, asks Dr Joss Bray
The situation in drug and alcohol treatment services is becoming increasingly dangerous. Because of commissioning pressures, enforced through contracts, services need to increase their number of ‘successful completions’ – which means many service users are being discharged from services abstinent from their drug of addiction and not on any prescribed drug replacement therapy.
While this may seem a good idea on the face of it, in practice it can be damaging and dangerous. The drive to get patients off scripts and out of services may be helpful for some, but for a lot more it makes relapse more likely.
Addiction is usually a chronic and relapsing condition that is not easily solved by a formulaic ‘one size fits all’ approach. We are now starting to see rises in drug-related deaths and drug use – both of which were previously declining.
Factors which contribute to this include the devolving of commissioning responsibility for drug and alcohol services to individual local authorities – many of which are very short of money and need to make significant cuts across the board.
Therefore, local politicians want to see obvious results for their investment in services, which many interpret as ‘successful completions’. This is in a climate where many services are having their funding reduced by at least a third – a short-sighted move as we know that money invested in drug and alcohol treatment shows at least a threefold positive yield in the wider economy.
While Public Health England (PHE) oversees the delegation of funds, including those for community drug and alcohol services, it has no power over commissioning and can only advise local authorities. It is left to local commissioners in each council to decide what services to commission. In some places, clinical commissioning groups also contribute a budget to drug and alcohol services – often because of a historic arrangement – but this is the exception rather than the rule.
The endless round of recommissioning every three years or so serves to destabilise services. The first year is all about taking over the service and establishing it so it works properly, employing and TUPEing staff and installing new operating practices. Then the second year settles down a bit, until the third year where staff and service users start to worry about employment, continuity and the next unknown provider. This cannot be a sensible way to provide, sustain and improve services.
There is also a real danger that providers underbid and over promise, then cannot provide the service needed because of lack of money for infrastructure and staff.
The Care Quality Commission (CQC) has been thinking again about how to inspect drug and alcohol services and measure quality, and it is actively working with service providers to optimise inspection regimes. In addition to the now standard criteria of ‘safe, caring, responsive, effective and well led’ there will be consideration of service users’ ‘needs and choices’ – a hopeful sign that inspections will acknowledge good quality of care, rather than focus on raw numbers of ‘successful completions’.
Evidence on best practice has been disseminated widely over recent years, but unfortunately, as the pendulum swings from one side of treatment fashion to the other, it has become all about ‘recovery’ (often requiring abstinence) rather then harm reduction.
This hotly contested debate misses the point. When someone is in need of help, there must be a full range of interventions available to them. It is up to the service user and the professional to decide between them on the best package. Anything that dictates, for example, that methadone scripts have to be time limited, is complete nonsense and goes against the available evidence.
There are many important measures of recovery, a script often being the least of them. Whatever the pros and cons of the Treatment Outcomes Profile (TOP) form, at least there is information recorded about crime, physical and mental health, work, education, drug use, risky behaviour, housing and overall wellbeing. Surely these sorts of outcomes should be what ‘success’ should be measured by, not by being off a script, out of a service and ticking a box.
The focus needs to shift back to the quality of individual care. There are ways of improving and assessing this which, if taken up, could radically improve services to those most in need. It should not be about getting numbers through the door as quickly as possible.
What people really want is what you or I would want for ourselves or our relatives and friends. When we see a professional for help we want them to be competent and compassionate. That is all. One without the other is at worst dangerous, and at best ineffective.
The professional should know how to find out what help I need, what the appropriate care is, how to ensure that I get it, and so on. They also need to be able to see where I am coming from in terms of my understanding, expectations and ability to use the strengths I have. That is competence.
The professional also needs to respect and care about me, to take a genuine interest, to have some feeling for what I am experiencing – and to be able to express that in some meaningful way, which makes me think that they will be doing their best for me. That is compassion.
Competent compassion encapsulates the ‘therapeutic relationship’ that is so often quoted as being the most important factor in successful treatment outcomes. It forms the basis of all therapy and treatment, whether abstinence-based, CBT, counselling, relapse prevention, substitute prescribing and harm reduction, or anything else in the treatment armoury.
The drug and alcohol treatment field is full of professionals, volunteers, ex-service users and others wanting to make a difference to people who have often been ignored or marginalised in society. The good news is that it is totally possible to help people make huge changes for the better – that is what keeps most of us going. The bad news is that the way the system works is not helping people receive the best individualised and evidence-based treatment.
We need to shift the focus away from the numbers of ‘successful completions’ back to improving the quality of care each individual receives – on a foundation of competent compassion. Only then will we see a lot more of what successful outcomes ought to look like.
Dr Joss Bray is a substance misuse specialist