Pockets of good practice throughout the country should not mask the fact that the ‘recovery agenda’ is failing, says Howard King.
Since the end of the last decade the substance misuse field has been increasingly focused on recovery. From the way we all talk about it you could be mistaken for thinking that there has been a substantial and consistent increase in the recovery rate nationally. Unfortunately that has not been the case, and indeed there is a marked absence in terms of any debate regarding how as a sector we are performing. So here are two figures that stand out.
1. According to the NDTMS website the current recovery rate for opiate users is 6.6 per cent – a drop from 8.59 per cent in 2011-12. For all service users the rate is 38.24 per cent – a rise since 2011-12 of just 3.52 per cent.
2. During the same period, drug-related deaths have risen and continue to rise. They have risen higher than at any point since data was first collected in 1993.
All major providers talk about their commitment to recovery, but what about outcomes? The evidence seems to indicate that as the recovery narrative has driven commissioning practice, the recovery rate has actually declined. We cannot ignore this clear disconnect between the narrative and the outcome.
If you were in central government and could see that all the investment into the field in recent years was achieving an annual recovery rate of only 6.63 per cent, and that this had consistently dropped year on year, then surely, in this time of evidence-based practice, you would want to review how you allocated resources?
Other areas of health and social care are expected to achieve so much more than the substance misuse field. IAPT (services for improving access to psychological therapies) for example, has a target of 50 per cent recovery. While it is important that we lobby for resources to be directed into people with substance misuse needs, perhaps we as a sector should also be doing more to actually deliver positive outcomes consistently across the country?
Of course it’s not just providers who are responsible for this current situation. Commissioners have played a central role in this also. Service specifications proclaim the need for recovery-focused services, but in most cases when commissioners change service providers, the recovery rate in the first year drops and it takes 18 months to two years for the new provider to achieve what the old provider was doing – if indeed there is any improvement at all. This isn’t good for service users and the view sometimes taken by commissioners that changing provider improves services is not generally supported by the evidence.
A recovery rate that has dropped to 6.63 per cent nationally proves that the current commissioning process is not generally achieving its goal. Changing providers on a regular basis does not seem to work and can negatively impact on patient care. Competition and best value is important but patient safety and consistency of provision should not play second best. Re-tendering is always an option, but one that should only be seen as a last resort when a service is failing and agreed remedial action plans have not led to the required change. It should not be the first response or an automatic reaction to contracts coming to an end, as evidence suggests this does not improve performance.
In addition to declining recovery rates, there is also the worrying trend of rising drug-related deaths. It is difficult to make a definite correlation between rising deaths, the emphasis on a recovery agenda which fails to deliver real recovery, and changing delivery models driven by increasing financial constraints. The emphasis placed upon an organisation’s ability, resilience and expertise in providing services that are correctly governed is often undervalued in procurements. The duty of care to service users extends not only to providers but also to those who commission services, and we all need to be held responsible for services when the recovery rate drops, drug-related deaths rise, trained professionals are replaced by unqualified staff and prescribing practice deteriorates.
This is not to say that the recovery agenda has not driven improvements in our field. Seeing the amount of peer-led recovery events that are taking place, the more powerful user voice and the ideas that are discussed about what recovery can mean, is hugely encouraging. However overall this shows that there are pockets of good practice, but these are not embedded ways of working that are consistent across the country. We can’t hide from the national figures or pretend to ourselves that it is everybody else or a handful of poor performing projects.
We do need to be careful about pushing a narrow concept of recovery onto those that aren’t ready or aren’t able. I am not suggesting that clients should be forced to reduce scripts or to detox against their wishes. The first aim of treatment should be to keep clients safe and harm reduction must be central to any treatment system, as should options for maintenance prescribing and long-term support. However, If we as a sector are saying that 6.63 per cent recovery is the best we can achieve without force, then we need to stop saying our services are recovery focused and look at other outcomes to prove what we are doing adds value to the communities we work in.
It’s time that we started to have an open and honest conversation in the field about recovery. While it is important to highlight good practice, it doesn’t change the fact that 6.63 per cent is a low recovery rate and the fact that more clients are dying is an uncomfortable truth. The reorientation of the drug treatment provider landscape may have reduced cost and increased competition, but it hasn’t brought a forward a leap in terms of recovery, innovation or best practice. Ironically a by-product of this is the demise of many small and medium sized drug treatment providers, creating a less divergent market place and potentially losing the localism that these smaller agencies provided.
We, providers and commissioners, need to do things differently if we want things to improve for service users. What we have now isn’t working, and funding will be lost if we don’t improve or change the discussion on what recovery means. Fundamentally it’s time that the sector actually offered meaningful, consistent, focused and evidence-based recovery-orientated services to our clients, based on an agreed range of outcomes.
Commissioners need to change their approach and not see re-tendering as the solution to their problems; if a service is working leave it alone and if it needs to improve, work with the provider to make it happen. Commissioners have tried financial penalties, retendering and changing providers, but in many cases the systems they oversee are producing worst results than they did five years ago. Isn’t it time to listen to the evidence and try a different approach?
We shouldn’t lose sight of the fact that many services provide a comprehensive range of effective interventions to service users, many of whom make significant lifestyle changes that improve their quality of life and also that of their family and wider community. We should celebrate these individuals and their success – but to say that as a sector we run recovery-focused services when so few of our clients achieve recovery is just not true.
Howard King is head of Inclusion