In a couple of days the country goes to the polls for one of the most unpredictable – and significant – elections in decades. As the outcome is likely to have a decisive impact on what the treatment sector, and wider society, might look like in a few years’ time, DDN decided to canvass opinion on what the new government’s priorities should be.
The first thing an incoming government should do is take drug and alcohol treatment seriously. While the period of top-level political attention and increased investment is over, it is still the case that effective drug and alcohol treatment makes a significant contribution to crime reduction, public health and social inclusion of the most marginalised groups. Treatment policy has been drifting – with no clear direction, and the beginnings of disinvestment – and needs to have a renewed focus.
This does not mean going back to ring-fenced budgets, or central control, but there has to be some more strategic planning to ensure that the reduced funds available are directed towards the most effective interventions. Any treatment strategy has to maintain the ‘menu of services’ approach that was established in the 1990s, but needs to give more support to services and mutual aid groups that help people move towards recovery. This is achievable within restricted budgets – many of these activities are relatively cheap, and there is still a lot of potential in the system to reduce spending on bureaucracy and ineffective interventions.
The best lever the government possesses to ensure its treatment policy is pursued around the country is to set strong indicators of successful outcomes – the opportunity to do this through the payment by results pilots was squandered by overcomplicating the metrics. In my view, any treatment pathway or system that can demonstrate that a fair proportion of its service users are not committing crimes, not receiving benefits, and are reducing their reliance on health and social services can claim it is worthy of investment of taxpayers’ money. The next government should set these clear expectations, and ensure commissioners and providers are judged by them.
I sit on the drugs, alcohol and justice parliamentary group who invited all the parties to come and tell us about their stance on drugs. Pretty much nobody turned up. Politicians see drug policy as a lose/lose debate – if they have a chance of winning a seat, they go quiet.
Theresa May in her introduction to the 2010 drug strategy said, ‘people should not use drugs, and if they do, they should stop.’ The approach is infantile, pandering to Daily Mail readers who might clamour for the disembowelling of anyone who cares for a stigmatised community. What I’d like to see from a new government is a grown-up conversation about evidence-based treatment and a new legal framework.
The current fiscal approach has absolutely no sophistication or insight. It is well known that for every pound spent on treatment, around five pounds is saved on healthcare, crime and harms to the wider community. I’d like to see an incoming government join the dots and deliver care; the kind that looks after people and saves money, not the kind that squeezes the vulnerable out of the system and spends infinitely more mopping up the damage.
I’d like to see services shaped by people whose needs are not being met, as well as those who have benefitted. The recovery agenda is pulling some people forward but it is leaving too many behind. I would like to see the next government return to holding people who need it, not pushing everyone forward whether they are ready or not.
Last year drug-related deaths went up by 32 per cent, but the treatment system is more interested in tweaking successful completion rates. I would like a new government to look at drug-related deaths as if they were the deaths of people who mattered.
Put simply, I want to see the progress that has been made in improving services over the past few years maintained and built upon. Time frames for working with addictions can be lengthy, therefore a reiteration of the principles of the drug strategy and a commitment to ensuring stability of funding – possibly at a lower level – is critically important.
I would also like to see public recognition of the value that third sector-organisations bring to fostering quality and innovation in the provision of services. The NHS public/private debate has the potential to damage the sector, and yet to date we have been virtually invisible in the dialogue. There needs to be a recognition that ‘not for profits’ operate from a different value base to their private counterparts, and that this ability to offer highly effective interventions that do not ‘drain’ money away from service provision can be advantageous at a time of enhanced budgetary pressures. Policymakers need to stay focused, maintain funding and keep pushing for innovation and outcomes that justify the investment.
The government’s move towards integrating health and social care is the right move on so many levels. There will inevitably be difficulties because it’s a long-term project that requires upfront investment, but nevertheless it has to be a key priority over the coming five years because of the potential it has to drive improvements in care for service users and patients. The challenge for us is to ensure our services are integrated into that system and not subsumed within it.
If I were to focus on one campaigning issue for the field, it would be tackling the stigma that has a devastating impact upon the lives of service users and long-lasting implications for their wellbeing and ability to recover. We need to be doing everything we can to tackle that by using our clout to influence key opinion makers who can help change enduing perceptions. The more people who understand recovery and what our service users can, and have, achieved, the more opportunities they will have to work and thrive. I never cease to be humbled by the commitment and resilience of people in recovery – stigma and ignorance is such an unnecessary barrier standing in the way of recovery, and it diminishes us as a society.
From a perspective of being a relatively small, but well-established, voluntary sector provider of recovery-oriented services, we feel that a new government should consider whether the relentless cycle of re-commissioning services every three or so years really benefits the end user.
This process can place a significant strain on the resources of smaller organisations such as ours without a full-time, dedicated bid-writing team. Short contracts do not always provide partnerships with the time required to really embed a new recovery culture or delivery model to best effect for service users. If services are to make a lasting influence and contribute to the origination and growth of recovery communities, then the impact on providers of this rapid cycle of change needs to be reconsidered.
At the very least, the new government could ensure that EU procurement laws designed to make opportunities more accessible for smaller organisations – by dividing large contracts into discrete lots – are adhered to by commissioners.
It feels like a tall order for providers to fulfill PHE’s logical ambition to bring alcohol treatment alongside drug treatment, after a long history of under-investment in the alcohol sector, and at a time when the ring-fenced budget for drug treatment has been removed. We have benefited from a good relationship with commissioners throughout the transition to PHE, based on a mutual understanding and shared goals. However, there is a real risk that local authorities across the country will direct their budgets into other more ‘deserving’ areas of need.
We fully support the current government’s emphasis on being ambitious for service users to achieve a full recovery – but too many providers appear to have jumped on the bandwagon, claiming to deliver this. Double Impact has always had a clear focus on being a specialist provider of recovery interventions and not a provider of clinical interventions. Through this experience, the organisation feels well placed to understand how to deliver a genuine recovery model and would ask the new government to commit to a more defined understanding of ‘recovery’ and measure performance against this.
Fundamentally, I would like to see the routine consideration of the needs of families affected by drugs and alcohol built into any drugs/alcohol policy adopted by the incoming government. The purpose of supporting families is twofold – firstly, they need and deserve support in their own right, and secondly, well-supported families are in a much better position to aid their loved ones through their own journeys of recovery.
So I’d like to see family support right up there, both as part of an ambitious treatment system and a vibrant and innovative community sector. And to back up this I’d also like to see, of course, some spending commitment that is much broader than ‘troubled families’ – effective and sensitive support for any family member in the country, no matter where they live. We are currently quite a way from this.
Drug and alcohol use has of course a strong correlation with the wider picture of social inequality, so I’d like to see a more just society. I think the wider policy area for us is really around the carers’ agenda – we’ve witnessed some good progress with the Care Act last year – so we’d like to see more recognition of those caring for people with drug or alcohol problems within the wider pool of carers. We are also concerned that a new government addresses the needs of the children of drug/alcohol users. Treatment for parents can improve outcomes for children, and parents who are able to care effectively for their children save government money by keeping them out of the care system.
The field needs to stop obsessing over the minutiae of recovery. Let’s all come together to try and promote a coherent voice to the ‘outside’. Sometimes convincing people of the need for support, investment and compassion towards anyone affected by drugs and alcohol can be difficult on account of the ‘well it’s their own fault, isn’t it?’ argument. We need to keep making the case for support for drug users and their families, both in terms of economics – it makes sense if you do the sums – and compassion.
With a growing number of jurisdictions implementing drug policy reform, including the ending of criminal sanctions for possession offences and regulated markets for cannabis, it will be hard for the next government to ignore the issue. The recent Home Office report that concluded that there was no obvious relationship between the toughness of a country’s enforcement against drug possession and levels of drug use clearly demonstrates that any government pursuing the current criminal justice approach is needlessly criminalising tens of thousands of people every year.
In terms of the treatment sector, Release would like to see the next government promote interventions based on the evidence rather than ideology, recognising the importance of harm reduction. That’s not to say that the availability of abstinence-based options is not important, but rather that we need a treatment system that responds to the needs and wishes of the individual, instead of one based on a political doctrine.
Something we talk about a lot at Release is how in many ways the problems our clients face are not strictly about drugs. As such we would like to see the next government revoke some of the worst aspects of welfare reform, including the bedroom tax, the restriction on social fund payments and the housing allowance cap, all of which have significantly and negatively impacted on many of those we represent. We would also challenge any government that brings in treatment conditionality for benefit claimants.
On the issue of policing, we would like to see the next government tackle the issue of our drugs stop and search laws and explore ways in which these could be reformed. These laws are having a detrimental impact on community-police relations and criminalising vast numbers of youth.
With the UK government spending £1.5bn on law enforcement but only £600m on drug treatment, we would like to see the field unite around the need to shift our drug policy from one based on a criminal justice response to one based on health, human rights and harm reduction. At the end of the day we should be advocating for the rights of those we represent, which should include that they are no longer treated as criminals.
Whoever forms the next government, and however it is formed, they will need to recognise that drug and alcohol treatment is changing. Services today must innovate in order to get better results from lesser resources and to cope with emerging challenges, such as legal highs and restrictions on other social care provision. This makes it imperative that services are able to cater for other health needs that are often co-morbidities with substance misuse issues, such as sexual health and smoking cessation. We must also reach groups such as the over-55s and those who misuse prescription medications. Policymakers must not fall into the trap of considering substance misuse services as somehow separate from the wider public health agenda.
With nearly three-quarters of substance misuse service users also experiencing a mental health condition, recent interest in mental health has been welcome, but mental health is only one of the many issues that can affect those with complex needs. Commissioners must make sure that contracts and funding encourage service providers to provide individuals with whole-person care.
In addition to integration within services, it is essential that health and social care organisations in a given community have the flexibility and freedom to work together. This is especially relevant to children and young adults, who may have seen substance misuse within the family. It’s vital that young people’s services are given adequate priority within organisational design and commissioning specifications, both to safeguard vulnerable individuals in the short term, and to prevent inter-generational dependency in the longer term.
In considering what I hope to see from the next government, my first response will always be about funding; specifically a greater commitment to interventions that work with the wider family. When we approach recovery as a single issue, we miss a trick. For every person receiving help, there are countless loved ones also in need of services.
The provision of effective support for family members and friends can prove a sound investment; they often provide the longer term love and care for people in recovery and can boost the fabulous work being carried out within mainstream services. It is sad to see the future of so many people determined by cost, as opposed to need. At Trevi House, the majority of our residents state that they would never have even considered entering residential treatment if it had meant separation from their children, yet cost invariably seems to be a barrier for so many others I speak to.
Funding is not all I would like to see. Politians, alongside the media, create a narrative around substance misuse, and have a key role in helping services to challenge the prejudice and stigma of dependency. I frequently hear people discussing addiction in moralistic tones; this is especially the case when we talk about mothers who are drug or alcohol users. I would invite the new government to come into our services – not with the press officer or the media advisor, but to come in and try to understand the work we do. I would ask them to be brave enough to declare their own previous drug use, or their personal battles with alcohol; to stop treating substance misusers as ‘them’ and not ‘us’.
I would ask the government to come and talk to women who have battled to recover from drug use, who have managed to break free from domestic abuse, who have managed to raise their children with little support and much judgment. I would invite the government to come and hear the real stories of people out there in recovery.
And you just never know, once they have done all that, the dream of more, better funding, might become a reality.
The government’s priority should be to ensure that adequate funding is available for both drug and alcohol services, and such funds should be supervised to guarantee that they will reach these important services. The government must also focus on prevention regimes that work. Solutions can be sought without reinventing the wheel on one hand or repeating past mistakes on the other.
In addition, it is essential to build confidence in commissioners. The quality of commissioners’ decision making directly affects the quality of service provision, so it is vital that the former is addressed in order to safeguard the latter. This requires accountability, which can only be promoted by making commissioners’ decision-making processes more transparent.
As a field, we should be campaigning for the destigmatisation of drug use. This is at the core of all the work we do, and could mean the difference between someone in trouble seeking help or struggling in silence.
Where is treatment going wrong? I believe the fault lies in common sense being ignored and not looking at the whole picture. Overall, community treatment in the UK is good – mainly from a few big national providers. The issue for me lies with the more complex clients and those who have repeatedly failed in the community.
Residential rehab is on the whole an ‘out of area’ placement, so common sense would be commissioning nationally rather than locally. Why would a local commissioner want to spend their budget sending someone to a completely different area from which they might never return?
Also community treatment is purchased in three- to five-year blocks, whereas residential treatment on the whole is spot purchased. How can a rehab plan and improve with no guarantee of income?
But by far the biggest waste of taxpayers’ money is local authorities using NHS services for services, especially inpatient detox. The outcomes for people being put in mental health wards at up to £500 a day are at best poor, and at worst putting people’s lives at risk. Specific units run by third sector organisations are shown to produce significantly better results for less than 50 per cent of the price, and are registered with CQC to ensure quality is not compromised.
When is an incoming government going to listen to those in the field with the actual knowledge and experience, rather than the big organisations looking out for themselves without the best interests of the clients at the forefront?
If I had one message to the incoming government regarding how we give people the best chance of achieving and sustaining recovery, it would be to plan ahead and invest in aftercare and the recovery community. These are so often the missing links in a successful, recovery-oriented system of care that achieve the best outcomes for individuals and their families – as well as a return on investment.
Aftercare and community support have traditionally been an afterthought. This doesn’t make sense as a coordinated and planned approach to people leaving treatment, building lasting recovery capital and integrating fully with communities are primers for sustaining change and not returning to treatment.
Ultimately, investing in aftercare and the recovery community will ensure the efficacy and value for money of treatment services, stopping the revolving door and reducing dependency on treatment services.
At Recovery Cymru our ‘recovery centre hubs’ are 365 days a year. It’s about living life – a community not a service. Our members include families and recovery advocates, as well as people ‘in’ or seeking recovery. But we are also a valued part of the treatment system in South Wales, offering support to people on all stages of their recovery and treatment journey, and working well with practitioners. This is exemplified by our recent collaboration with a treatment (Solas) and training (Newlink Wales) provider to deliver integrated aftercare, volunteering and recovery community support to people in Cardiff and the Vale of Glamorgan. We have been commissioned to do this, recognising the value and impact on efficacy of treatment services this will have.
The incoming government needs to promote this model, understanding the importance of a coordinated approach to collaborative aftercare and the recovery community. Developing the culture of recovery nationally would help to avoid black and white thinking and be a true investment in the workforce.
The incoming government will find a situation changed beyond recognition compared with 2010, nationally and internationally. In the UK, polling shows a majority of the public in favour of decriminalisation of possession, or legal regulation, of cannabis, and over two-thirds in favour of a comprehensive review of our approach to drugs. Support runs across party political affiliations, and most media outlets – including the Sun – now back reform.
Internationally, taking an actively prohibitionist line is becoming increasingly difficult for the UK. Latin American trade partners, including Mexico and Colombia, are criticising the drug war and calling for alternatives to be explored. Multiple US states have legally regulated cannabis, and if California legally regulates it in 2016 then cannabis prohibition in the US will be over. A swathe of countries across the Americas and Caribbean will follow suit – as Uruguay and Jamaica already have – and European states will join the anti-prohibition wave.
So the door is open for the incoming government to make a commitment – real this time, not rhetorical – to deliver evidence-based policy nationally and internationally. To that end, we would like to see them build on the Home Office’s international comparators report that showed harsh drug laws do not reduce use (DDN, December 2014, page 5), by initiating a comprehensive independent review of UK drug policy, comparing our current approach with alternatives like Portuguese decriminalisation and models of legal regulation. This would lay out the evidence for reform and provide political space to develop cross-party support to implement it.
So what should we be campaigning for? A number of groups in the field, including service providers like Blenheim CDP, Westminster Drugs Project and Kaleidoscope have already signed up to our Count the Costs campaign for a review (www.countthecosts.org). But whether through that coalition, or other routes, we would like to see all groups in the field pressing the incoming government and all UK political parties to support a review.
The resulting report will make it much harder for politicians and media to blame drug users for the failings of their prohibitionist approach, or conflate drug use harms with those caused by our punitive drug policy. As a result, we will genuinely be able to manage drug use and misuse in a way that is just, effective and humane, and campaign more effectively for the true root causes of the ‘drug problem’ to be addressed.
The UKRF held its first event in May 2010 one day after an election that brought the Coalition to power, bringing with it five years of ‘austerity’. Ten days away from our next election the Guardian reports that ‘Britain’s billionaires have seen their net worth more than double since the recession, with the richest families now controlling a total of £547bn’, an increase of more than 112 per cent. The Equality Trust says that ‘the richest 1,000 families have more money than the poorest 40 per cent of British households combined’ with their wealth increasing last year by £28bn, the equivalent of £77m a day. Meanwhile the public sector has seen massive restructuring and rebranding, creeping privatisation and huge cuts.
The most vulnerable victims of a neo-liberal agenda that has put profit before people for decades, have found themselves disregarded, sanctioned and vilified as responsible for their woes. While those that work within our economic ‘recovery’ find themselves increasingly trapped in insecure jobs and zero hour contracts, the unemployed (the antithesis of ‘hard-working families’) are categorised within a new deserving and undeserving poor narrative. Nowhere is this more evident than in the DWP and the words and deeds of Iain Duncan Smith, the principal proponent of a politicised ‘recovery’ that puts abstinence before social justice and economics before equality.
Five years on, we live in a more unequal society and the gap is growing. As Professor Hanlon of Glasgow University put it, ‘modern society: unequal, inequitable and unsustainable’. So in an ‘age of dislocation’, as our communities fragment and fray and people reach for comfort in all sorts of unhealthy ways, I think the government’s priority should be honesty as to the roots of the problems we all face, and the wider community recovery we all need. Perhaps then we’ll begin to find real solutions?