On the eve of the publication of the second part of the Carol Black review, delegates at a Westminster Social Policy Forum event debated the state of the sector and where we go from here. DDN reports.
People with drug dependency were ‘almost the equivalent of the cast-out lepers of former times,’ Professor Dame Carol Black told the told the Westminster Social Policy Forum’s Tackling drug addiction and substance misuse – latest thinking on prevention, supporting recovery, policy and findings of the independent review event (see news, page 4).
Drug dependency was a ‘complex, stigmatised problem’, she said. ‘Those dependent on drugs are not owned by any one department of state. You might say it’s too messy, too difficult, while at the same time of course creating personal, familial and societal misery and costing the government, we calculated, some £19bn per year.’
Failing system
Part one of the review had addressed supply and demand (DDN, March 2020, page 4), revealing a ‘failing’ system and increasing levels of drug supply, county lines activity and violence – a ‘dire situation’ that had then ‘met austerity’. Since 2014 there had been a 17 per cent fall in funding for adult drug services and a 25 per cent fall for young people’s services. ‘And in a few areas of the country, that fall for adult services has been as much as 40 per cent.’
There was ‘obviously a lot to do’, she stated. ‘This is a report about system change, and reflects the fact that drug dependency has never been tackled in a determined and coordinated way by six departments of state’ – the Department of Health and Social Care, Home Office, Department for Work and Pensions, Ministry of Justice, Department for Education and Ministry of Housing, Communities and Local Government. Rather it was each department trying to do a small amount but not in a way that was joined up, she said.
‘I spent many hours talking to people who are drug-dependent, and they tell you what they need to achieve recovery. Medicine is part of this, but then so much is jobs, friends and housing. I also want to ensure that thriving communities of recovery are a component of every drug treatment system, and this needs to be country-wide. People with lived experience offer so much to the recovery journey that clinicians are simply not equipped to do.’
Support and engagement
There were multiple ways that people in recovery contributed, but a critical one was creating and leading support organisations, said advisor to the review, professor of psychiatry at Stanford University and former drug policy advisor to Barack Obama, Dr Keith Humphreys (DDN, June 2012, page 16). ‘For most people, this is the work of years, which means there’s a need for organisations that persist in people’s lives and engage with them for a long time.’
Talking about recovery was the ‘exciting, positive, happy thing that happens in this field’, when so much discussion was around issues like illness, violence and death, he said. ‘It’s not just “I’m no longer using heroin”, but “I have a job, I’m back together with my family, I feel valued, I feel I’m contributing.” Those things take a long time to develop, but are critically important for health and quality of life.’
Recovery organisations had a different rationale for what made someone an expert, he said. ‘The helping is reciprocal. When a doctor sees a patient it’s not appropriate to ask the patient for help with the doctor’s problems, but in these organisations one moment you can be the helper and in the next the helpee. One of the interesting findings in social support literature is that giving support is probably as good for our health as receiving it.’
Crucially, these services were also free, he said, or operated on a voluntary ‘coin in the basket’ model. ‘That makes them available to anyone, regardless of their economic situation.’ While some had a designated programme or philosophy, others were more general and by no means all were abstinence-orientated. ‘It’s good that there’s so much diversity, so people can find something that works for them. And it’s not just all about services, it’s also about cultural and political influence. We had a saying in the White House – “if you don’t have a seat at the table, you’re probably on the menu.” It’s very important that people in recovery are at the table in all discussions, and Dame Carol did a huge amount of outreach and involvement of people in recovery throughout her work. We need that expertise and that wisdom.’
The public component was also vital, he said, as could be seen with recovery walks. ‘If you’d said 20 years ago there’s going to be 500 people with drug problems marching down the street most people probably would have locked their doors. Now they come out and applaud. Seeing people who they previously might have crossed the street to avoid as successful parents, workers, citizens is very powerfully destigmatising and hope-inspiring.’
Key Ingredients
To deliver high quality, well-led services needed three key ingredients, said Dr Linda Harris, chief executive and clinical director of Spectrum Community Health CIC and chair of the health and justice clinical reference group at NHS England. ‘But they’re huge. We need a positive culture, a capable workforce with the capacity and headspace to care safely and with compassion while being able to train and supervise the workforce of the future, and we need a team of teams. There’s no one agency that can solve this issue, so we need to collaborate to continually improve and innovate.’
There was also a ‘post-pandemic societal context’, she added, with the move to remote and flexible working and the digitisation of service offers. Competition for talent was a key issue, with an ongoing health and social care workforce crisis – ‘we really have to get those sharp elbows out.’ Successful recruitment and retention meant competitive rewards and competitive terms and conditions. ‘We want substance misuse services to be that great place to work, and that also means training and development.
‘I think we can market our strengths,’ she told the event. ‘COVID has shone an enormous light on health inequalities and their root causes, and I think we can take our rightful place leading some of these population health interventions. I’m optimistic because I think this is a pivot moment and providers are ambitious and poised to push to new heights in quality improvement and achievement in the sector. But we do need to invest now.’
The Next Chapter
‘We’re really at the start of the next chapter in the history of our field,’ agreed director of Collective Voice, Oliver Standing. There was not only the second part of the Black review, but also technological innovation and the fact that the sector was becoming much more informed about the links between trauma and addiction.
‘We’ve had the £80m in funding, the Black review’s dominating all of our thoughts, PHE has been cut in twain with the senior jobs at the Office of Health Promotion being recruited at the moment,’ he said. ‘Then there’s the Comprehensive Spending Review in the autumn, the NHS reforms, and an addiction strategy probably at the start of next year.’ And all were contingent on each other to a greater or lesser extent, he stated.
‘Politics is all about momentum and we’ve got a window of opportunity here, but we need that political leadership. We need a robust political response to the review, and we need the funding to continue to support the work. We mustn’t forget we’re in the middle of a drug-related death crisis. This is a morally catastrophic thing, and we can’t ever forget that.’
Professor Dame Carol Black
Professor Dame Carol Black DBE FRCP FMedSci chairs the boards of the Centre for Ageing Better and Think Ahead, the government’s fast-stream training programme for Mental Health Social Workers. She is expert adviser on health and work to NHS England/Improvement and Public Health England and until August 2019 was principal of Newnham College Cambridge. She is a member of Rand Europe’s Council of Advisers, the board of the Institute for Employment Studies, the board of UK Active, and the advisory board of Step up to Serve.
She has authored three independent reviews for the UK government: of the health of the working-age population in 2008 as national director for health and work; of sickness absence in Britain in 2011 as co-chair; and of employment outcomes of addiction to drugs or alcohol, or obesity, in 2016. She is currently working on a fourth independent review for government, of illicit drugs in England.
Dame Carol is a past-president of the Royal College of Physicians, of the Academy of Medical Royal Colleges, and of the British Lung Foundation, and past-chair of the Nuffield Trust for health policy. The centre she established at the Royal Free Hospital in London is internationally renowned for research and treatment of connective tissue diseases such as scleroderma. She has been a trustee of the National Portrait Gallery.
As principal of Newnham, Dame Carol was on several committees in Cambridge University, and she remains a patron of the Women’s Leadership Centre in the Judge Business School, and a member of the university’s advisory board on student mental health. In 2018 she was appointed chair of the British Library Board. Biography at bl.uk/people/experts/carol-black