I have been a community-based drug and alcohol worker since the late ’90s. Much has changed – some positive, but mostly very negative – over the last 15 years. Most of my time was spent in the third sector and over the first ten years I was very proud of this. Often at the vanguard of harm reduction, we clearly had a positive impact on society – reducing drug-related deaths, IV-related harms, HIV and BBVs.
Back then drug teams were staffed by very experienced professionals from a range of backgrounds, contributing to a skill mix that served the client base well. Our roles were varied and we held caseloads of no more than 25-30, which gave us the cognitive and emotional capacity to deliver. A mix of Tier 2 and 3 work felt like a good strategy for worker wellbeing. New innovative projects, approaches and services all seemed to make the field head in a direction that would eventually tip over into real policy change.
Skip forward to 2025 and we are faced with the ‘corporatisation’ of that third sector – behemoth charities vying for funding in a race to the bottom. The result? Unrealistic bids accepted by poor commissioning processes throughout the country. Many experienced staff have left because of extreme burnout from exceptionally complex caseloads to be replaced by young, inexperienced staff who are lucky to receive a few sessions of e-module-based training. They are told to ‘shadow’ colleagues for learning and then given caseloads of 50 and above. Their colleagues don’t have time to support them as they are also sinking, then burnt out in a year or two. Some return; most don’t.
As drug and alcohol workers we are hearing people’s stories and trying our very best to deliver interventions. But with these caseloads how are we supposed to retain everyone’s story in a meaningful, reflective way? In some areas workers have simply become OST monitors.
Pay continues to be depressed – in 2001 I was on £24k and I know some services are still only paying this. The caseloads and complexity, combined with unachievable contracts and current HR and management practices are leaving people psychologically and emotionally exhausted – quite clear from observing sickness and staff retention rates. Micromanagement is rife, with further stress from chasing KPIs, which can translate as workers being far more focused on evidencing the work than doing the actual work – often on computer systems not fit for purpose.
Dame Carol Black’s review highlighted some of these issues, but the field has been promised a recognised qualification standard and meaningful workforce plan for aeons. However, while the voices of service users and service CEOs is heard, the workforce is not. I have seen many people come into the field with massive potential to help those living with addiction, only to leave again.
Our policy direction is opposite to where it needs to be. With new emerging threats, harm reduction should be expanded rapidly. Addiction needs to be recognised as the public health issue it is – and while I understand the need for a criminal justice element within the sector, it should not be the dominant focus.
I have many colleagues and friends who share this experience up and down the land. Most of the small local independent charities that developed our approach have disappeared, swallowed up by corporations. There seems to be a lack of drive from CEOs to lobby government and be innovative – or maybe even daring.
The opening of the Glasgow safer injecting facility is the first real innovation for a while. The UK pioneered the harm reduction model and yet we have found ourselves years, if not decades, behind our European and Commonwealth neighbours. There is still a huge amount of fantastic work being done across the nation – however, I fear this is in spite of the above and not because of it. The norm is an overstretched workforce suffering poor mental health and, in some examples, providing a skeleton service. I’ve heard of people in some areas having caseloads of 80 – and you are literally only doing telephone contacts and OST management at this number.
I’m writing this to shine a light on fundamental issues, for the workforce in particular. The constant drive for increased numbers in treatment without a correlating investment in the workforce is destructive, whereas a healthy workforce working with a trauma-informed approach and a balanced number on their books would have positive outcomes for service users. I have a passion for the field and a huge desire to see change before I get too old and retire.
I am currently fortunate to work in a specialist team within an NHS service. A reduced caseload and good worker support means I can focus on my job and deliver to a good standard. We’re a multidisciplinary team of staff with years of experience, but that’s not to say we don’t have our issues as the pressures are the same everywhere.
I do not want to detract from the good work that is completed every day in the field, but after knowing people who have suffered mental health episodes, divorce and even a return to a former drug dependency, I feel the issues for the workforce should be investigated properly, to hold power to account.
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