Disinvestment in harm reduction is hurting services and failing clients, say those struggling to maintain life-saving provision. DDN reports. \u2018A couple of weeks ago I had a call from the BBC, asking if I could speak on their breakfast show about issues faced by a pharmacist in Staffordshire,\u2019 says Philippe Bonnet, chair of the National Needle Exchange Forum (NNEF). \u2018The pharmacist said he was thinking of stopping needle and syringe programmes (NSP) because of safety reasons \u2013 his staff were being abused regularly. He mentioned a couple of incidents where a service user threatened a member of staff with a used syringe, demanding they give him needles. On another occasion someone came into the dispensary with a knife, demanding their methadone and threatening to kill.\u2019 Bonnet pleaded with the pharmacist to reconsider, asking him \u2018not to punish everyone because of the actions of a couple of individuals\u2019. He mentioned that NSPs were the reason that HIV prevalence was low in the UK, compared to Europe, and that giving out equipment is so much cheaper than the treatment for blood-borne viruses. He did not get an answer from the pharmacist when he asked him if he was going to stop dispensing methadone. Philippe Bonnet: 'Needle and syringe programmes are being forgotten about.' To the casual listener, the conversation on the radio may sound like discussing sensible precautions on staff protection. But for those working in harm reduction it is another red flag in a public health emergency. The ease with which people who need these services are being dismissed is being compounded by a crisis in funding and staff morale. \u2018In some services, NSPs are being forgotten about,\u2019 says Bonnet. Mark (not his real name) works in the harm reduction team of a large treatment agency, and says there has been \u2018a steady erosion of knowledge about harm reduction approaches since 2010\u2019. Large cuts to funding have meant \u2018caseloads of increasing complexity\u2019 and evidence-based practice being replaced by \u2018a mush of dubious interventions\u2019, including an over-reliance on urine testing. \u2018Significant numbers of drug-related deaths this year, including several believed to be linked to fentanyl\u2019 have not prompted a relevant response. \u2018The focus appears to be more on data requirements rather than interventions around reducing risk,\u2019 he says. \u2018There has been no information about fentanyl circulated by the manager or the organisation, in stark contrast to the constant emails related to data needs.\u2019 Furthermore, he sees a slide towards a deskilled workforce. Within increasingly complex caseloads, \u2018much of this work is done by recovery workers who are relatively new to the field but have received little or no training other than shadowing colleagues\u2019. Amy (who also asked for her name to be changed, because she feels she is in a \u2018speak out at your own risk working environment\u2019) manages a needle exchange and has worked in drug treatment services for the last five years. During this time she has seen \u2018the steady erosion of vital aspects of harm reduction\u2019. \u2018The stuff we know works \u2013 assertive outreach, consistent and persistent support for treatment-resistant individuals \u2013 has taken a back seat in favour of assessment, TOPS and group work,\u2019 she says. \u2018There is so much pressure on \u201cpositive outcomes\u201d that ultimately very little energy is spent nailing the basics. Ultimately the pressure and expectations we have to impose on our clients is mammoth. The system feels designed for the chaotic to fail \u2013 and why wouldn\u2019t it be? Fewer chaotic clients in treatment means fewer drop-outs, fewer representations, and all of a sudden your positive outcomes and numbers are on the up.\u2019 While Amy acknowledges some good initiatives \u2013 \u2018naloxone has been a game-changer, as long as you turn up to a service to pick it up\u2019 \u2013 ultimately, she says, \u2018we know that there are so many of our most vulnerable \u2013 in the car parks, out camping behind Tesco, sleeping in the underpass \u2013 that cannot or will not come into treatment to access such potentially life-saving interventions. What about them? We are not going to get to them, that\u2019s for certain. There\u2019s no time, no strategy, and barely enough staff to keep the hubs running. Yet again, these folks fall through the cracks.\u2019 As well as not receiving the immediate help they need, clients are missing out on a much bigger opportunity to engage with healthcare. \u2018NSPs for many people represent the first, and possibly only, engagement with a \u201cprofessional\u201d agency,\u2019 says Kevin Flemen of KFx training. \u2018This toe-hold in a service opens up routes to so many other interventions \u2013 overdose prevention and naloxone, vaccines and BBV testing, wound care and treatment. It can be the first tentative step on a longer treatment journey.\u2019 For many it will also offer the right environment to discuss OST and life-changing options for stabilisation \u2013 steps that not only transform the individual\u2019s prospects, but also reduce the harm to their families and ultimately to society. Kevin Flemen: 'Needle exchanges open up routes to so many other interventions.' As a trainer he has a fair idea of the level of staff knowledge, and also of the level of priority that harm reduction is getting within services. At the moment he sees that we are devaluing it \u2018by failing to provide space, time, privacy and resources to make needle exchange excellent. All too often, staff with no training dole out equipment with no discussion or further engagement.\u2019 He sees that \u2018some areas have no trained staff or dedicated space for NSP\u2019. As injectors turn to using lower-threshold pharmacy services, this is seen as a further reason to keep downgrading this essential service. Amy\u2019s colleagues in another service from the same provider have told her about the \u2018no bin, no pin\u2019 policy there to encourage returns, getting rid of pre-injection swabs \u2018for good old soap and water \u2013 great! Unless of course you don\u2019t have access to such facilities!\u2019, and ceasing the distribution of water ampoules because of unfathomable \u2018concerns around legalities\u2019. According to Amy, a little investment in her needle exchange would go a long way. There are the material items that could be bought with more money \u2013 the BBV testing kits and homeless packs; and the specific services they could provide, like access to a nutritionist, wound care specialist or dentist. But what the service really craves is \u2018to reduce pressure on staff, invest in quality training and nurture specialisms\u2019. \u2018One of the heartbreaking things to watch over the last few years is how so many of my colleagues with a love and speciality for harm reduction have moved into other areas of the care sector, or even out of it entirely. Why? Because it\u2019s not worth the heartache,\u2019 she says. \u2018You either have to leave because it\u2019s too much, or suck up your pride and principles and get on with the work at hand.\u2019 \u2018Most importantly,\u2019 she says, \u2018we need to really take a step back and reduce the threshold for those accessing support \u2013 it can\u2019t be that we turn away the chaotic, dependent injecting drug user because they are ten minutes late for their appointment. We need to be present, consistently \u2013 not just from nine to five in an office, but at 6am in the car parks and at 10pm out with the working girls.\u2019 Amy thinks that introducing key performance indicators (KPIs) for harm reduction might be the way to regain energy and focus, and redress the attitude that \u2018no one really cares about what we do or don\u2019t do on the front end\u2019. Having \u201860 clients on your caseload and a mountain of admin on your desk\u2019 translates to telling the client \u2018take your script and I will see you in two weeks\u2019, instead of giving them the time and energy required for a meaningful working relationship. Amy: 'We underestimate the power of a cuppa and a chat.' \u2018We underestimate the power that just sitting down and having a cuppa and a chat, with no expectations, can have. We need time and we need patience, and unfortunately there is no pot of funding for that,\u2019 she says, adding: \u2018I regularly sit in team meetings in which discharge stats are sniffed out like dogs with a bone. These are people\u2019s lives!\u2019 Mark is also weary of the attitude that \u2018NSP cover is something that can be delivered by anyone, often admin staff\u2019. He believes that the initiative must be taken by treatment providers, in the same way that naloxone distribution has (eventually) been embraced. Just three years ago he remembers that a senior man\u00adager in one of the larger organisations was instructing members of staff that they \u2018must not talk about naloxone as we are not a campaigning organisation\u2019. Many organisations are still silent about issues such as drug consumption rooms (DCRs) and heroin-assisted therapy, perhaps taking their lead from the government\u2019s drug strategy, which (while acknowledging that we should protect society\u2019s most vulnerable) only fleetingly mentions harm reduction and ignores the importance of outreach. \u2018The providers of treatment really need to start to use the language of harm reduction and be clear about a commitment to those approaches, rather than continuing with a culture of harm reduction by stealth,\u2019 says Mark. \u2018If they don\u2019t believe that they should do everything possible to campaign for initiatives and interventions that can reduce the numbers of deaths among their service users, then we are in an impossible situation.\u2019 This article has been produced with support from Camurus, which has not influenced the content in any way.