Is the focus on recovery undermining a highly skilled workforce? As Neil McKeganey said in 2010 (in Controversies in Drugs Policy and Practice), if you need to visit a doctor you can rest assured the person you are seeing will have had a medical education. If you want to buy a house you know that the solicitor has been educated to degree level, and if you take your dog or cat to the vet you know that they will be one of the most highly trained professionals around. But if you see a drug worker you will probably be seen by someone who has not been to university, does not have a professional or postgraduate qualification, and who may have only just entered the field. At a conference on Workforce development: challenges, opportunities and the way forward, speakers from different specialisms painted a picture of a sector in danger of paying the price of undervaluing essential skills, and asked, are we compromising service users’ safety by ‘doing it on the cheap’?
‘There are half a million nurses working in this country, but I’m not sure where our voice is’, said Dr Carmel Clancy, head of department of mental health, social work and integrative medicine at Middlesex University, who is also chair of the Association of Nurses in Substance Abuse (ANSA).
In the 1960s nurses were working in regional drug dependency units (DDUs) and the 1980s saw an increase of nurse specialists in community drug and alcohol teams. In the 1990s nurses were central to harm minimisation and there were nurse consultant roles – but the title of nurse was now becoming interchangeable with key worker and drug worker.
‘Non specialists are taking over nursing roles,’ she said. ‘Nurses are there, but are not as visible. How do we claim a stake at the table?’
The sector had ‘no idea’ of the number of nurses working in addiction, with many falling into it by default, through promotion or changing location. Despite nurses seeing addiction as a specialism, they did not receive any undergraduate training on it and felt they were starting again when they came into addiction, said Clancy.
Changes were afoot however, with ANSA’s proposed merger with the International Nurses Society on Addictions (IntNSA) in July, which would strengthen the nurses’ voice and raise their profile in the addiction workforce.
The law change on ‘non-medical prescribing’ in 2012 (extending the right of a professionally qualified person to prescribe) had resulted in a growing number of nurse prescribers, added Mike Flanagan, consultant nurse and clinical lead for substance misuse services at Surrey Borders Partnership NHS Foundation Trust and chair of the National Substance Misuse Non-Medical Prescribing Forum.
The changing landscape of the last ten years had seen drug and alcohol treatment more performance monitored than any area of health and social care, he said. When commissioning moved to local authorities in 2013, the sector had been subjected to repeated cycles of retendering with diminishing budgets, all of which had contributed to making specialist addiction treatment a less attractive career option.
So what had been the impact on nursing? Medical roles were increasingly provided by non-medical prescribers – which was fine if properly supervised, said Flanagan. But with nursing posts increasingly provided by drug workers, there was ‘a risk that commissioners and managers may fail to fully appreciate the impact on quality.’
The psychologist: ‘Everyone does psychosocial interventions’
Many of the barriers and facilitators to change were psychological, but ‘absolutely everyone’ did psychosocial interventions now, including staff and service users, said Dr Christopher Whiteley, consultant clinical psychologist at South London and Maudsley NHS Foundation Trust.
The ‘recovery juggernaut’ had involved everyone in ‘building recovery capital’ – human, physical, cultural and social – which had helped to address issues of confidence, joining in meaningful occupations, maintaining accommodation and staying in recovery.
But there were challenges: with many of the psychosocial interventions being undertaken by people who were not psychologists, outcomes were greatly affected by the quality of the working alliance.
Organisations were prone to heavy caseloads, high turnover of clients and a lack of resources for training. To be effective there needed to be synergy between leadership, a culture of innovation, training and supervision, he said, while more could be done with families, peers and community networks.
Addiction doctors: ‘We’re an endangered species’
Addiction specialist doctors were becoming an endangered species, according to Dr Kostas Agath, medical director at Addaction. Decreased availability of addiction psychiatry training posts brought with it disappearance of skills. ‘Once my generation has expired you cannot download us from the internet,’ he said.
Throughout the disruptive environment of retendering we needed to make sure training plans were robust, he said. The way forward in preserving the disappearing specialism relied on a national sphere of influence, but also local sustainable solutions.
‘Localism shapes the context – one size does not fit all,’ he said. Future-proofing psychiatrists’ roles involved effective integration with GPs, non-medical prescribers, pharmacists and psychologists.
Social workers: ‘We need specialist knowledge’
‘Of 90,000 social workers in the UK we have no idea how many specialise in alcohol and drug use’, said Dr Sarah Galvani, professor of adult social care at Manchester Metropolitan University’s department of social care and social work, who had ‘more than 30 years of identifying the lack of drug and alcohol knowledge in social workers’.
Alcohol or drug problems were identified as criminal justice or health problems, which explained the lack of engagement with social workers.
‘But the vast majority say alcohol or drug education is very or extremely important to their practice,’ she said. ‘Most social workers can talk – but they have a problem talking about substance misuse as they don’t know what to ask.’
Social workers could have three key roles – to engage with people about the topic of substance misuse; to motivate people to change and support them in doing this; and to offer follow-up support to maintain changes.
The challenges included political constraints and direct government intervention into social work education, with the devaluing of specialist practice on substance misuse. There was dissolution of specialist teams and roles, with whole services being cut and others going to the cheapest bidder.
But there were also clear opportunities, said Galvani, including the move of specialist services towards holistic and recovery-oriented approaches and embracing the wider health and wellbeing agenda, which was ‘social workers’ bread and butter’.
We were lucky to have a strong evidence base, new teaching partnerships and an increasing number of resources relating to social work and substance use, she said. ‘We need to take the opportunities.’
A long and winding road
With a clear set of challenges ahead, the Scottish Drugs Forum is learning lessons from the past in developing its workforce programme, said George Burton
‘Scotland has had a long-standing alcohol and other drug problem and has been disproportionately affected,’ said Burton. Drug-related deaths were stubbornly high and had increased again, with last year’s figure of 613 the highest ever recorded.
Looking back, policy responses in the 1980s had been rooted in harm reduction and methadone, until the newly elected SNP introduced a strategy of ‘drug- free recovery’ in 2008 (and a ‘new hostility to methadone’). Drug services began changing their names to take on recovery, with drug workers becoming recovery workers.
But the quality of services depended on the quality of professionals. How much was the ‘strategic objective’ to recruit people in recovery about money and levels of pay?, he asked.
A two-tier workforce had meant that agreements on outcomes between the health service and voluntary drug and alcohol services were ‘difficult to develop, when one half of the workforce [the NHS] was paid considerably more’ and there was ‘such disparity across providers’.
Alcohol and drug partnerships (ADPs) across Scotland were aligned to local authorities, and support teams included officers for different functions, such as development, policy and research, some of whom ‘had no knowledge of drugs and alcohol but were responsible for big commissioning decisions’.
The Scottish Drugs Forum (SDF) provided training, which covered an introduction to the field, motivational interviewing, stigma, recovery outcomes and new drugs, as well as offering strategic support to ADPs for quality development.
A survey of service users also suggested the workforce needed local knowledge, flexibility and non-judgmental practice, and some suggested they benefited from ‘lived experience’.
‘Workforce development is becoming understood as more than just training, but it’s taking time and it’s still early days,’ said Burton.
Among the SDF’s current priorities were the national naloxone programme, work on quality development and service improvement, strong user involvement including a programme to train people in recovery to join the workforce, programmes on hepatitis and needle exchange, and work with the Scottish Prison Service, including dealing with NPS in prisons.
The absence of a clear pathway to the drug and alcohol field meant there was a rich mix of people with a range of experience, ‘but we need to pay properly – this race to the bottom is not acceptable,’ he said.
‘It’s important to recognise that most people can’t do this type of job,’ he said. ‘But being in recovery does not make you a recovery worker.’
George Burton is workforce development programme manager at the Scottish Drugs Forum