Annette Dale-Perera talks to David Gilliver about the challenges facing NHS treatment providers, and how the sector should be responding to a new era
Annette Dale-Perera has been strategic director of addiction and offender care for Central and North West London NHS Foundation Trust (CNWL) since 2009, when she left her role as director of quality at the NTA. As well as its partnership arrangements with seven local authorities, CNWL runs an inpatient unit, problem gambling and club drug clinics and a new behavioural addictions service, while its offender care side operates substance services in more than 10 prisons. It’s an impressive list, but as she told delegates at DrugScope’s conference (DDN, December 2012, page 13), she’s worried about the shrinking number of NHS providers and loss of essential health skills, particularly given some of the acute health needs associated with emerging drugs.
One problem is a view that persists of some NHS organisations being insufficiently ‘recovery focused’, or averse to change. ‘It depends on whether you mean recovery or abstinence,’ she says. ‘It also depends on what the organisation is like – primary care organisations have an absolute deep-seated grounding in health and wellbeing outcomes, so it doesn’t make sense to me to say they’re not embedded in the recovery agenda. I’d always try to broaden it so that it’s not just about reducing dependence – it’s about improving health and wellbeing and people’s quality of life.’
CNWL has been carrying out Department of Health-funded work on cultural change in organisations, informed by recovery in the mental health field. ‘There’s a lot we can learn from some of the recovery work that’s been done in mental health, and realistically I think the only way services in the future are going to be able to survive is by a mix of experts-by-experience, volunteers and paid staff in new ways of working.’ There’s no doubt that the recovery approach has been ethically driven, she believes, ‘but I think our hands are going to be forced on this one through the economic situation’.
Many NHS organisations with mental health services approach recovery from a different perspective, she says, ‘and where that’s happening it’s really fruitful. But again the problem is that staff in NHS organisations are more expensive and in some places teams that were once multidisciplinary have been reduced to nurses and the odd doctor.’ CNWL has one of the country’s surviving addiction psychology teams, she adds. ‘I think if we do lose psychology expertise, the world will be a worse place.’ And nurses and doctors remain vital, she stresses. ‘There seems to be this reductionist thinking that medical staff only do opiate prescribing, which is rubbish. They should be utilised to promote physical and mental health and wellbeing, from blood-borne viruses to nutrition – a whole bunch of things.’
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She’s also warned in the past about reading too much into encouraging statistics about falling rates of drug use. ‘All the trends in things like the British Crime Survey show that lots of types of drug use are going down, and that’s kind of indisputable. But my issue with that kind of survey is that it misses out a significant chunk of the people who are using, primarily young adults – the marginalised communities and offenders don’t answer the questions, so I think it under-represents a whole section of society.’
There’s also a whole range of substances that are not covered, she states – understandably, given the rate at which new psychoactives are being detected – with staff at CWNL’s club drug clinic often struggling to get their clients onto systems like NDTMS as ‘there’s only a finite number of drugs you can list’.
The extent to which the sector has been target-driven around heroin and crack has also meant that, until recently, other drug users and alcohol users weren’t prioritised. ‘If you provided treatment for them it didn’t count towards your key performance indicators that were linked to money. So I think we took our eye off the ball around things like powder cocaine in particular.’
All of this has been compounded by ‘decimation’ of funding for young people’s services, she points out. ‘Part of the problem is that few young people are dependent per se, but there are an awful lot who are bingeing on alcohol, stimulants, smoking strong cannabis and, increasingly, taking club drugs which may have acute harms. I think we’ve missed the point by applying adult KPIs to young people’s services when input is needed for different patterns of harmful substance misuse.’
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Dale-Perera has also been a UK expert delegate on drug demand reduction to the UN, where it was ‘fascinating to see the different countries not wishing to upset each other,’ she says. ‘The power of the American delegation is hugely apparent at those kind of meetings, and what’s also apparent is how much they invest in and fund the research – we’re dominated by American research, and it’s something they do well, but at the time [2008] they’d try to squash anything to do with harm reduction, which was very sad. I think the EU has done a lot to forge links with the Latin American countries, particularly Spain and Portugal, because they have a cultural affinity and shared history to some extent, but I do think we need to do things much more on a global scale.’
On that note, the aspect of the Home Affairs Committee’s report (see page 4) she was most struck by was producer nations stating that ‘this isn’t working for us and we’re in a mess’, she says. ‘I thought that should really make us all sit up and think – it’s not just about preventing the harm in this country, it’s also about what is happening on a global level.’
Any UK government that took a different approach would have to do so in its first term or early in a second, she says. ‘It’s difficult for politicians because they feel they need to be seen as tough. I still think it’s tragic that a lot of young adults get criminal records for drug possession offences, and that puts people on such a difficult trajectory.’ It’s not a burden that’s shared equally across society, either, she stresses. ‘More young adults who get criminal records are from deprived or working class areas, so it’s a class issue, and more black and minority ethnic people get criminalised as well.’
She spent seven years at the NTA before taking up her current position. How does she look back on her time there? ‘I think the NTA did wonders to champion the cause of drug treatment, particularly under the previous administration, and it kept the money flowing in. We’ve got more treatment penetration than almost any country in the world, which is a really good thing. The NTA had some really good initiatives but we didn’t get everything right.’
There’s been much reflection on the NTA’s treatment effectiveness strategy, she says, and while it was the ‘the numbers in and the retention’ that were prioritised in targets, finding a way of prioritising ‘the ins, outs and recovery at the same time’ might have yielded more.
‘But it’s very easy to say these things in retrospect. When you’re at an organisation like the NTA you’re really responding to what’s happening among the providers, the commissioners and, very importantly, what’s happening in government at the time.’
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On top of her demanding role at CNWL she’s a member of the Advisory Council on the Misuse of Drugs (ACMD) and co-chair of its new recovery committee, something she’s particularly excited about. ‘It’s the only other standing committee of the ACMD apart from the technical one with all the chemists. We’ve tried to get it so that a significant proportion of people on the committee have lived experience, either through using substances or having family members who have used substances, and we’re going to look at different aspects of recovery over the next few years.’
Her commitment to the sector partly grew through having a series of ‘inspirational teachers and managers’ throughout her career, she says, from Robin Davidson and Duncan Raistrick at Leeds Addiction Centre to Gerry Stimson – ‘who trusted me enough to manage a new unit’ – and on to Roger Howard at SCODA/DrugScope and Paul Hayes. ‘I thank every one of them to this day. I’ve been really lucky.’
While she remains cautiously optimistic about the move to Public Health England, she’s ‘deeply concerned’ about reductions in health and social care infrastructure and funding. ‘I don’t think we’ve really realised how potentially devastating it’s going to be, and the only way of getting through this is to have some radically new models. The IMF predict that by 2017 UK public spend per capita will be below that of the USA, and that’s really scary.’
NHS trusts are now trying to plan for the next three years under the shadow of at least 20 per cent in cost improvement programmes, she warns. ‘That’s before there’s any kind of cuts to central funding budgets. It’s very frightening.’ DDN