How do we harness political support when priorities lie elsewhere? In the sixth of his series of articles, former deputy drug czar Mike Trace sizes up the challenge…
Twenty years ago, the Labour government positioned substance misuse treatment as one of its key social policy priorities and increased central government investment by more than 400 per cent. These were the golden days of political support, but we are now in a period of central government indifference, linked to significant budget reductions.
When the NTA closed down, I remember Paul Hayes and Department of Health officials urging the sector to work hard to convince ministers, local councillors, and directors of public health of the financial and policy merits of substance misuse treatment.
This was reasonable advice, as it was clear that we were leaving a period when policy support and generous budgets were assured, and our sector would have to compete with more mainstream concerns, within the context of a local government financial squeeze.
But it was also a bit of a cop out – the big decisions that affect the level of focus and investment in the sector had already been made: the closure of the cross-government agency set up to act as a custodian; the end of the central government drug treatment ‘pooled budget’; the incorporation of that money into a wider local authority public health grant; and the removal of the ring fence on that grant.
The period since those decisions were made has seen politicians at local and national level talk widely about the value of substance misuse treatment, but no serious attempts to reverse the decline in resources or develop new or expanded services.
So what ‘big wins’ can the sector offer to policy makers to rejuvenate the sector? Unfortunately, not all of the benefits we see from the treatment system can be translated into political support and increased budgets.
Substance misuse treatment reduces blood borne infections?
The fear of drug-related HIV and hepatitis infections has receded as transmission rates have declined and treatments have improved. The cost/benefit analysis of public health prevention measures remains positive, but there is no sense of the crisis that is needed to stimulate policy action.
Substance misuse treatment reduces drug-related deaths?
The shocking level of drug-related deaths has also not been enough to trigger a significant reaction. It seems true that drug users’ lives are seen as less important – if we had more than 3,000 early deaths per year due to traffic accidents or knife crime, we would be witnessing national campaigns and bold new investments. We also have a problem in claiming treatment can significantly reduce deaths. Policy makers will ask why the death rates have gone up throughout the period when the number of people in treatment expanded massively.
Substance misuse treatment reduces crime?
This was the argument that most interested ministers when I was in government. And the theory was largely proved correct, with the types of crime most associated with dependent drug use declining significantly between 2000 and 2010. Whether it holds the same potency now – when volume crime rates are lower, and enforcement priorities are moving more towards violence reduction and organised crime – is questionable, but the financial case remains compelling; treatment reduces offending, which in turn significantly reduces criminal justice expenditure.
Substance misuse treatment reduces social exclusion?
This has in my view always been the sector’s trump card. Our sector deals with a high proportion of the most socially marginalised individuals. They experience, and cause, multiple problems beyond drug and alcohol dependence. If our interventions can reduce those problems – homelessness, family break-up, unemployment, low-level mental health problems – then it is meeting the objectives of many central government departments. Unfortunately, we have not been very good at demonstrating our impact in these areas – research has been patchy, and our commissioning data sets do not provide sufficiently clear results.
Substance misuse treatment reduces health service utilisation?
This seems plausible, and there is some research to show reductions in, for example, A&E presentations, GP appointments, or liver failure. But we still do not have any comprehensive data on the impact we have on our clients’ use, and costs of other NHS services. I would imagine that such research would demonstrate a strong case for substance misuse treatment as a cost-effective prevention measure within NHS strategic plans.
There is a pathway to re-energising political support for our sector, but I fear that we have not been making the right arguments, or assembling and presenting the right evidence. The scramble for resources in a time of austerity is brutal but inevitable – to protect existing budgets, or gain support for new developments, the substance misuse treatment sector needs to offer big gains in a policy area that the politicians and public care about.
While our public health achievements are worthy of celebration, they will never rise to the top of local authority or NHS priorities. It is more likely that rejuvenated interest will come from the social inclusion agenda – helping people to move from positions of deprivation and dysfunction into work, stable accommodation, and positive connections with family and community. And while it is true that the current national government is not at all focused on social inclusion, it will not be in power much longer.
Local governments will always see the benefits of moving people into jobs, and helping them off homelessness or social service registers. We need to offer them a clear, and evidence based, vision of what can be achieved. The long overdue appointment of the government recovery champion – Dr Edward Day – presents an opportunity to articulate this vision at the highest levels. My next article will contain some suggestions for how he can go about this task.