Can we meet six basic challenges to repair a fragmented treatment system, asks Paul Hayes.
Brexit continues to dominate mainstream debate. But far more important to most people, particularly the poor, the marginalised, and the ‘left behind’ is the cumulative impact of years of austerity and the continuing failure of the economy to grow.
The prime minister’s promise to overcome the ‘burning injustices’ which blight so many lives, seems distant. The reality of sluggish growth, falling wages, and slow but steady degradation of the services on which the poor and vulnerable rely, provide the context in which drug and alcohol treatment providers work and our service users live.
Below are six of the key challenges facing the drug and alcohol treatment system during 2018. As the government recognised in last year’s drug strategy, truly effective interventions depend on their cumulative impact. People need adequate access to physical and mental health treatment, a realistic prospect of a job, a safe place to live, and enough income for food and clothing.
Since the financial crash of 2008, the cumulative impact of squeezed budgets and changes in policy have placed strains on service users’ capacity to survive and recover, which treatment providers cannot address in isolation – no matter how brilliantly they implement the drug strategy or how assiduously they abide by the clinical guidelines.
******* ALCOHOL *******
Only one person in six who needs alcohol treatment is able to access it. Alcohol harm is concentrated in our poorest communities, with 30 per cent of all alcohol consumed by 4 per cent of the population. The health damage, the societal consequences and the costs to the NHS are well understood. Despite this, the government has thus far resisted publishing an alcohol strategy identifying how it will reduce the overall harm of alcohol use and in particular how it will close the gap between the growing need for treatment and shrinking capacity. There is growing political pressure for the government to be more active in social policy, and an alcohol strategy would be the ideal place to begin.
******* DRUG-RELATED DEATHS *******
The Local Government Association, PHE, and the ACMD have all identified treatment for England’s heroin-using population as the key to reducing drug-related deaths. Being ‘in treatment’ is a protective factor: deaths are significantly lower within the 60 per cent in contact with services than the 40 per cent who are not. Every local authority commissioner and provider should be striving to understand why people do not access services and find the most effective way to reach them. However, with providers extended to the limit to meet the needs of the 60 per cent, resourcing will be fundamental to success.
******* DISINVESTMENT *******
In 2012/13, total spend on drug and alcohol treatment in the community and prison was more than £1bn. It is now around £750m. Local authorities are increasingly focusing their commissioning on ‘must haves’; protecting rapid access to prescribing services by limiting the availability of the wider services that are crucial to success – those relating to homelessness, mental health, employment, offending, and services specific to gender, culture and communities. As services become hollowed out, the spectre looms of a government committed to recovery presiding over a system which is forced by financial constraints to focus almost exclusively on maintenance prescribing.
******* FRAGMENTATION *******
The 2013 reforms brought drug and alcohol treatment together as the responsibility of local authorities – but elsewhere we have seen fragmentation of provision rather than its integration. Most significantly, as the cohort of heroin users from the late 20th century epidemic age, their need for mainstream health services has grown dramatically. Decades of heroin use, accompanied by smoking, poor diet, insecure accommodation, fragile mental health, and alcohol misuse, has created a population with severely compromised heart, lung and liver function, whose health needs are more akin to those of the elderly than the middle aged. A hard-pressed NHS struggles to respond to those it experiences as ‘challenging’, and service users are easily discouraged by the bewildering range of NHS signposts and pathways.
Health and wellbeing boards, created to knit local authority and NHS services together, are preoccupied with the massive challenge of integrating health and social care and pay scant attention to lower priority issues such as alcohol and drug treatment. The impact of this is that a vulnerable population is excluded from healthcare, resulting in unnecessarily early deaths – in far greater numbers than the overdose deaths reported in the drug-related death figures.
A similar chasm has been allowed to develop between prison and community services. Since 2013 prison drug and alcohol treatment has been commissioned by NHS England and usually delivered within large multi-site contracts with generic healthcare providers. Startlingly this means that neither the Ministry of Justice nor NHS England know how much is spent on drug and alcohol treatment in custody – however the MOJ’s best estimate suggests that prison treatment has also experienced a 25 per cent reduction since they assumed responsibility. Before this, prison and community treatment was commissioned as one system to facilitate effective transfer between the two settings. The failure of the current system is illustrated by the fact that only 30 per cent of those assessed as having a continuing need for treatment on release actually establish contact with a community service.
******* COMPLEXITY *******
The narrowing of local authorities’ ambitions for their specialist treatment systems is accompanied by continuing decline in the generic services that are fundamental to recovery. Despite the government’s laudable commitment to parity of esteem for mental health within the NHS, the secretary of state has acknowledged that the need to recruit and train enough doctors and nurses will delay the achievement of this aspiration for many years.
The abject failure of the government’s Transforming Rehabilitation reforms of the probation service dramatically curtailed the support available to offenders serving community sentences, and on licence following imprisonment. In addition, the probation service is now largely absent from local strategic planning processes in which they used to play a prominent role. While these failings are largely hidden, what is visible in cities across the country is the dramatic increase in street homelessness, which has doubled since 2010 and increased 16 per cent over the past year. This is only one facet of unmet housing need for people with drug and alcohol problems, but it is currently the most visible manifestation of the failure of society to meet the needs of its most vulnerable citizens.
******* CRIME *******
The government’s modern crime prevention strategy, launched by then home secretary Theresa May in 2016, identifies drug treatment as one of society’s most effective tools to reduce crime. Home Office analysis attributes half the rise in acquisitive crime at the end of the 20th century to the impact of the heroin epidemic, and a third of the reduction this century to the improving availability of treatment from 2001 onwards.
The clear connection between heroin/crack dependence and crime made the police strong advocates of improved treatment access, and they were extremely influential players in drug treatment policy between 2001 and 2010. Over the past decade police interest in drug-related offending and their advocacy of treatment diminished as acquisitive crime continued to fall and priorities shifted to sexual offences, violence against women and girls, cybercrime, and terrorism.
Very recently there has been some reawakening of police interest in drug treatment. Traditional crime is beginning to increase; burglary is up by 8 per cent; theft from vehicles is up by 15 per cent; drug-related gang activity is becoming more of a concern and appears to be linked to increasing use of firearms. Use of firearms declined significantly alongside other drug-related offences from 2005 onwards but the most recent crime figures show an increase, including a 20 per cent increase in the use of handguns. None of these increases can be exclusively linked to the drug market, but if ready access to a well-funded drug treatment system helped crime fall between 2000 and 2010 we should not be surprised to see a reversal of the trend.
Despite the scale of these overlapping challenges there are reasons to be optimistic that we can find effective ways to respond. The drug strategy is a huge step forward in endorsing evidence-based practice and explicitly recognising the breadth of the responses needed to succeed. The routine denial of issues such as disinvestment and fragmentation that characterised official responses before the publication of the strategy has been replaced with greater willingness to own the scale of the challenge and seek pragmatic solutions. The increase in traditional crime creates a rationale for police to renew their advocacy of treatment, which has significant potential to shape local investment decisions.
Most importantly, the home secretary now chairs a cross-government board to drive this agenda forward. Her leadership, supported by the objective grassroots view of a newly appointed recovery champion, and underpinned by the willingness to hold local authorities to account (via PHE) for their delivery of key metrics, provides the best opportunity in a decade to address the complexity and scope of the problems facing service users and their communities.
Paul Hayes is head of Collective Voice