A Public Health Priority?

The reforms to the planning and commissioning of drug and alcohol services that have been the subject of so much speculation finally became the day to day reality for the sector from 1 April. The National Treatment Agency (NTA), which has been such a prominent feature of the drug policy landscape since 2001, closed its doors at the end of March, with its functions absorbed into Public Health England (PHE). The ‘pooled treatment budget’ which has funded the expansion of drug services in England, came to an end, with this funding absorbed into a new public health budget.

So how big an impact will these changes have on service delivery on the ground and what is DrugScope’s role in supporting our members as we enter what feels like a new phase in the politics, planning and delivery of substance misuse services?

PHE published ‘Our priorities for 2013-14’ on 26 April. It includes a commitment to ‘improve recovery rates from drug dependency, recognising this as the core purpose of drug treatment’. There is, however, only one further reference to drug dependency, and two references to alcohol. By contrast, the word ‘local’ makes 48 appearances. The PHE priorities document stresses that ‘improvement in the public’s health has to be led from within communities, rather than directed centrally’ and adds that ‘PHE will not performance manage local authorities’. This sounds like a more ‘hands off’ role than was adopted by the NTA, with PHE largely dependent on its powers of persuasion.

For those imagining that the transfer of NTA functions into PHE might result in business as usual, it is worth noting that around 150 NTA staff have joined an organisation with over 5,000 staff. In addition, the NTA has not been ‘lifted and shifted’ into PHE, but fragmented and split across three separate Directorates. Rosanna O’Connor, formerly the Director of Delivery at the NTA, is now the most senior figure with a specific substance misuse brief in PHE, as Director of Drugs and Alcohol in the Health Improvement and Population Health Directorate. Yet she has no direct management responsibility for the drug and alcohol teams in the 15 regional PHE Centres (formerly NTA regional teams), which sit under a separate Operational Directorate. The National Drug Treatment Monitoring System (NDTMS) and National Alcohol Treatment Monitoring System (NATMS) are housed within PHE’s Knowledge and Intelligence Directorate. How all this will work out in practice remains to be seen.  

What is clear is that Government is serious about ‘localism’ and local authorities will have more discretion about what funding is allocated to substance misuse services and how it is spent. This has prompted real concerns about the risks of disinvestment particularly during a period of financial austerity, with the Spending Review 2010 including a 28 per cent reduction in the local government settlement (once funding for police and fire authorities are excluded) up to 2014-15.

DrugScope – working with our colleagues in the Recovery Partnership – had previously got a reassurance that drug treatment spending would be protected. In June 2012, the Department of Health published an ‘Update on Public Health Funding’ that reported the findings of its Advisory Committee on Resource Allocation (ACRA) that, at least for an interim period, ‘the allocation of the PTB for drugs treatment should continue to follow the approach currently used and praised as effective by the National Audit Office’. However, when the local authority allocations for 2013-14 and 2014-15 were published we struggled to see how any meaningful protections had been incorporated into those budgets.

In March, DrugScope’s Chief Executive, Martin Barnes, wrote to Health Minister Anna Soubry MP to ask whether any protections had in fact been included in the public health budgets and how they would work. The reply from the Minister that we received at the end of April conceded that is was not possible to identify a nominal ‘drugs allocation’ within the budgets announced in January, which places a question mark over the possibility of any meaningful protection. The Minister says that the Department of Health will ‘keep the provision and funding of substance misuse treatment under close review in the first year’. This is welcome, but it also suggests that the Government shares the concerns. It also raises the question of what government would do if there was disinvestment given its commitment to localism.

DrugScope has launched, for the Recovery Partnership, a Recovery Watch initiative and is encouraging members and others to get in contact with us where there is local disinvestment. We are also developing a DrugScope Observatory to monitor local developments and to ‘hold a mirror’ up to national and local government. Later in the year, we are planning a national survey of service providers to assess the impact of the reforms on their work, so watch this space and keep in touch.

Dr Marcus Roberts - DrugScope Director of Policy and Membership

Integrated approaches for women with drug and alcohol problems

I recently joined DrugScope as Policy and Engagement Officer. I have a strong interest in women’s issues, and was therefore particularly pleased that the importance of integrated services for women with drug and alcohol problems is an area that DrugScope has been concerned about for some time.

The LDAN/DrugScope Domestic Violence project, which ran for four years and came to an end in March, worked to encourage collaboration and facilitate partnerships between the domestic violence and substance misuse sectors, given the clear, though complex, links between intimate partner violence and problematic alcohol and/or drug use. Research has, for instance, identified that women who have experienced gender-based violence are 5.5 times more likely to be diagnosed with a substance use problem over their lifetime.[1] 

A 2005 report by the Mayor of London also found that almost two-thirds of the women it surveyed from domestic violence agencies with substance misuse problems reported that they began their problematic substance use following their experiences of domestic violence. All of these women saw a link between their substance misuse and their experiences of domestic violence, with the most common reported being use of substances to dull physical and emotional pain. 

As the final report for the DrugScope/LDAN project – which will shortly be available here –  sets out, national strategies have often failed to address these dual issues, and joined-up approaches have, historically, been lacking in frontline services. We held an end of project event in London on 26th March which also highlighted the continuing limited availability of female-only provision, and the impact that this can have on women using services. Presenting findings from the evidence gathering stage of their ‘Rebuilding shattered lives’ project, Anna Page of St Mungo’s noted that professionals and service users alike have made arguments for both mixed and female-only provision. She highlighted, however, that, according to their analysis, female clients in women-only provision make more positive progress than those in mixed services.[2]

Emerging findings from a forthcoming DrugScope and AVA (Against Violence and Abuse) research report on sex workers’ experiences of drug and alcohol services – to be published in Summer 2013 – also point to a lack of integrated working, in spite of the links between sex work and substance misuse, and particularly use of drugs.[3] This should also be seen in the context of national policies that fail to make the necessary links: the 2010 Drug Strategy, for instance, makes no reference to the words “prostitution”, “woman”, “women” or “girl”.

There is a risk that, as new local commissioning structures come into play, the provision of appropriate services for women will continue to be overlooked. Within local authorities, Directors of Public Health (DsPH) have a broad range of responsibilities, and there are concerns that the needs of the most vulnerable and marginalised groups may go unnoticed. Additionally, from next year, the Community Safety Fund, which Police and Crime Commissioners are responsible for allocating across police force areas, will be rolled into the main policing grant, exacerbating the risk of disinvestment still further.

But the new arrangements also bring fresh opportunities for joined-up, women-specific services. Statutory guidance recently published for Health and Wellbeing Boards, which are responsible for producing the needs assessments and strategies that DsPH will commission on the basis of, specifically sets out the importance of considering “those with complex and multiple needs”. Additionally, the Public Health Outcomes Framework, published by the Department of Health last year, sets out a range of relevant indicators, including on domestic abuse, sexual violence, alcohol and drugs, mental illness, homelessness and reoffending.

At the end of March, the Ministry of Justice also published ‘Strategic objectives for female offenders’, which sets out key priorities in relation to women in contact with the criminal justice system, and announces an independent advisory board to push these forward. After a decidedly slow start on provision for women offenders (particularly disappointing given the lead provided by the Corston report in 2007), these are welcome steps by the Government. Importantly, the new document acknowledges the specific, and often multiple needs of women who offend, and reiterates the importance of services in the community that recognise and address these.

It’s worth noting, too, that the policy focus on multiple needs is being matched by funders’ increasing recognition of the importance of integrated services. Lankelly Chase, for instance, now focuses solely on work that tackles complex needs, and the Big Lottery Fund has recently announced its ‘Fulfilling lives’ programme, which is investing £100 million into services supporting people with multiple and complex needs. It is crucial that, as this agenda moves forward, the multiple and specific needs of women with substance misuse problems are clearly recognised within this, and addressed.

Gemma Lousley, Policy and Engagement Officer.


[1] Rees, S. et al (2011) ‘Lifetime prevalence of gender-based violence in women and the relationship with mental disorders and psychosocial function’, Journal of American Medical Association, 306/5: 513–521.
[2] http://www.ldan.org.uk/powerpoints/DVFinalAnna%20Page%20St%20Mungo.ppt
[3] http://www.ldan.org.uk/powerpoints/DVFinalSex%20workers%20experiences%20of%20drug%20and%20alcohol.ppt

The Future for Safer Future Communities?

In Members’ Briefing of March 2012, we wrote about Safer Future Communities (SFC) – a Home Office funded network of networks aiming to support the voluntary and community sector to engage with the agenda around the new elected Police and Crime Commissioners (PCCs), who from April 2013 will set local priorities around policing and crime prevention, as well as controlling a proportion of the money that has previously flowed into the sector via the Drug Intervention Programme (DIP).

With Clinks as the lead partner supported by strategic partners including DrugScope and a broad stakeholder group, the project has been funded to:

• Provide practical support and advice to organisations that support Home Office objectives in preparation for the arrival of PCCs
• Support the sector as it adjusts to the changing local delivery and commissioning landscape
• Enable VCSE organisations to be in a position to become effective partners with the statutory sector and provide cost effective services, including involvement in co-design and co-delivery of services that meet local needs.

Going from a standing start in much of the country, SFC supported the establishment of a local network in each of the 42 police areas gaining PCCs in the 2012 elections (including London, who had gained a PCC in the form of the Mayor earlier that year), mostly but not exclusively led by local infrastructure organisations. Altogether, around 4,200 voluntary sector organisations have joined local networks.

Unfortunately, in April 2013 the current funding expires, and the outlook is uncertain. That Home Office funding for the project has finished now is disappointing, given the large amount of work that remains to be done in shaping and commissioning services and the phased nature of the PCCs’ assumption of control over budgets (which will not be complete until April 2014). In the context of the priorities above, how successful has SFC been, and what does the future hold?

To turn first to successes, SFC has been a powerful voice for the sector in many local areas, and particularly for smaller organisations who otherwise might struggle to make themselves heard. The very nature of elected PCCs means that as individuals, they value different approaches, want to be responsive to local issues and feel obliged to adhere to their manifesto commitments.

Consequently a one size fits all approach was never going to be effective, and local networks have been pursuing their own lines of engagement with PCCs with varying degrees of success. This work was hampered by the moving of the elections from May to November 2012, which had the effect of compressing the time available for PCCs to create their first Police and Crime Plans and to start managing their budgets.

Turning to the future, some local SFC networks will be funded by their PCC, others are in negotiations with potential funders including PCCs, whilst the national strategic steering group has agreed to continue its work, in all likelihood at an unfunded and consequently a reduced level.

Engaging with PCCs will remain important to many VCS organisations and particularly so for the drug and alcohol sector, given the resources that will go to PCCs’ Community Safety Budgets from DIP and the strong results delivered to date as a result of arrest referral routes.

In addition to community safety, PCCs are expected to be key players in commissioning cross-cutting services that work across different strands of the new environment, including Public Health.  Agencies whose work currently meets crime and community safety objectives, who currently deliver DIP or who believe that they could offer something that would fit with local PCC community safety priorities could still consider contacting their local SFC lead partner to find out what the plans are for the local network.

DrugScope has produced a briefing about PCCs for the sector, and has other resources that might be of interest. They can be found on our website here. You can find more information about Safer Future Communities here, and “Why Invest” from the NTA, a briefing about the impact treatment has on reducing crime and reoffending here.

Paul Anders, Senior Policy Officer, email: paula@drugscope.org.uk

Poverty: the state of being extremely poor?

A recent government consultation has been looking afresh at the issue of child poverty - DrugScope, Adfam and Alcohol Concern submitted a joint response. 

The Labour government elected in 1997 made the reduction of child poverty, which had increased substantially since the late 1970s, a priority area. Some progress had been made but by the mid-2000s that had stalled [1], hampered by stagnant or falling real incomes in some parts of the job market, rising costs and unemployment.

In 2006, the Conservative Party signed up to the then Labour government’s ambitious target of ending child poverty by 2020 [2] and supported the Child Poverty Act 2010 [3], whilst claiming that many of the children who had benefited from Labour’s policies were in households that had only just been lifted above the income  poverty line – “poverty plus a pound”, in the words of Nick Clegg.

The 2010 Act set four criteria for measuring poverty and targets to meet by 2020, primarily relating to relative, persistent and absolute poverty, and material deprivation – broadly the same measures taken across the EU and beyond.

The consultation

One of the drivers of the recent consultation [4] is that a fall in median income from 2008 onwards had appeared to lift some children out of poverty [5] ; they hadn’t become better off financially, the change was due to an average decline in income. This appears central to the matter at hand – relative poverty, as a percentage of median income, has been represented as a moving goalpost, or a cat chasing its own tail [6]. 

To describe it in this way is to misunderstand or misrepresent the difference between the mean and the median. Counterintuitive results, whilst not ideal, do not necessarily represent a sound reason for abandoning measures of relative household income as indicators of child poverty.

The recent consultation proposes a multi-dimensional measure of poverty that could risk burying relative (and absolute) low income under layers of complexity and data about related but largely separate factors and characteristics. The proposed components are:

• Income and material deprivation
• Worklessness
• Unmanageable debt
• Poor housing
• Parental skill level
• Access to quality education
• Family stability
• Parental health

Whilst there is a case to be made for some or all of the above forming part of a measure of childhood disadvantage, there are potential problems – not least that some could confuse cause with effect.

This is particularly so in Dimension 8: Parental Health. Whilst the title of the proposed measure is innocuous enough, the definition of health contained in the consultation appears to extend little beyond (undefined) disability, mental ill health and drug and / or alcohol dependency, the last meriting an individual consultation question.

This is concerning as it risks conflating households in poverty and people with drug or alcohol dependency, despite a paucity of evidence as to the direction of any causal relationship. The prominence given to drugs and alcohol increased when the Secretary of State, Iain Duncan Smith MP, introduced Public Views on Child Poverty [7] in a high profile speech. This research – based on a public opinion survey – suggested that respondents thought that drug or alcohol dependency was more important than income in deciding whether a child was growing up in poverty.

Drug dependency is a serious issue for those affected, but it is potentially a factor for a minority of children in poverty  – in 2003, the Advisory Council on the Misuse of Drugs estimated that up to 350,000 children in the UK were growing up with one or both parents drug dependent, compared to a total number of children in poverty at that time of almost 3,000,000 (in the UK) [8].

For alcohol use, there is additional complexity, with patterns of alcohol use and dependency diverging from drug dependency at different points on the income scale according to a range of factors, not least gender – for example, high-income women are more at risk from dangerous levels of consumption than those on low-incomes.

As the consultation states, it is entirely correct that the final measure chosen should be accepted by the public as a meaningful representation of child poverty, but government should proceed with caution, do everything possible to ensure that policy is grounded in evidence , and avoid the risk of reinforcing stigma.

You can read the consultation response here.

You can find a recent map of child poverty using the measures contained in the Child Poverty Act 2010 here.

Paul Anders, Senior Policy Officer, email: paula@drugscope.org.uk

<!--[if !supportFootnotes]-->
1. http://research.dwp.gov.uk/asd/hbai/hbai2010/pdf_files/full_hbai11.pdf
2. http://www.guardian.co.uk/commentisfree/2006/apr/11/comment.politics2
3. http://www.legislation.gov.uk/ukpga/2010/9/contents
4. http://www.official-documents.gov.uk/document/cm84/8483/8483.pdf
5. http://research.dwp.gov.uk/asd/hbai/hbai2010/pdf_files/full_hbai11.pdf page 16.
6. http://www.telegraph.co.uk/news/politics/conservative/7803983/Poverty-is-about-much-more-than-money.html
7.http://statistics.dwp.gov.uk/asd/asd1/adhoc_analysis/2013/public%20_views_on_child_poverty.pdf
8. http://research.dwp.gov.uk/asd/hbai/hbai2010/pdf_files/full_hbai11.pdf

Employment and welfare reform – why bother?

DrugScope’s policy team is busy working on a wide range of issues that are impacting on the drug and alcohol sector, including public health, Police and Crime Commissioners and payment by results. As may have become apparent over the last few months however, we have been paying increasing attention to welfare reform, employment initiatives and DWP active labour market interventions such as the Work Programme. Given the potential for substantial change in the sector, it would be reasonable to ask why we’ve accorded this such priority.

The Drug Strategy explicitly recognises the importance of accessing training and employment in supporting recovery. There are, of course, broader positive reasons for people to seek and (hopefully) find and sustain paid work. As a matter of principle, we broadly agree with the conclusions contained in the frequently cited report by Waddell and Burton – Is Work Good for Your Health and Wellbeing?  Work is often a route out of poverty and towards greater financial and personal independence – although with a strong caveat that the quality of the work in question is crucial. There is persuasive and plausible evidence that suggests that insecure, low-paid, low-status work involving irregular hours and poor terms and conditions is not particularly good for one’s health and wellbeing.

Conversely, there are other reasons why some might feel the need to seek employment – aspects of welfare reform will increase conditionality (the things that people need to do to remain eligible for benefits), including for some people on Employment Support Allowance. We need to ensure that individuals are able to safely navigate the transition to Universal Credit, as well as managing the other changes due over the course of the year – the phasing in of Personal Independence Payment to replace Disability Living Allowance (DLA), the overall benefit cap (likely to be around £26,000p.a.), the localisation of Council Tax Benefit and a new claimant commitment that will demand more of jobseekers than has previously been the case. The abolition of the discretionary social fund (community care grants and loans) from April 2013 will also potentially impact on people with drug and alcohol problems. Alongside these changes, there are new offers aimed at supporting recovery, such as tailored conditionality for people entering “recovery orientated treatment” – this is a positive step, and we will be working with the Department for Work and Pensions (DWP) to try to ensure that the detail contained in the guidance matches the policy intent, which is to allow people to remain focussed and supported during a crucial phase of treatment.

With sanctions (suspension of benefits) already extended to up to 3 years via the interim regulations that came into effect towards the end of 2012, claimants will need a good understanding of how the new systems will work and how to access the right sort of support should they encounter difficulties. There is growing international evidence that the effectiveness of sanctions and conditionality is limited for chaotic and vulnerable claimants, and the sector needs to ensure that its clients are not treated unfairly or prejudicially. The National Treatment Agency (NTA) has, along with Jobcentre Plus (JCP) and Work Programme providers, recently released a new joint working protocol that may mean that people get a service that is a better fit to their needs, but we know that disclosure and identification remains a problem when frontline JCP or Work Programme staff often lack the skills or expertise to enable such a discussion, whilst the view of people with histories of drug use, often informed by experience, is that by disclosing they will receive not a better service, but a worse one.

Finally, with regard to the impact of the Work Programme on the sector and the people it serves. Speaking to agencies, whether or not they’re on Work Programme supply chains, the impression we’ve formed is not so much one of a business opportunity that didn’t materialise so much as an acute sense of frustration that proven, effective programmes and partnerships have had support removed or reduced, whilst the needs of those furthest from the job market do not appear to be being met though mainstream, generalist initiatives. In 2013, DWP will be piloting new approaches in the Work Programme to people with histories of drug and alcohol use. This is a welcome development and is one we will be watching keenly.

DrugScope has submitted evidence to the Work and Pensions Select Committee and will be giving evidence in person on the 30th January 2013. You can read our submission here, and can watch the session online here. You can also find more information about our LDAN Employment Project, including resources for treatment providers and Work Programme providers, here.

The Recovery Partnership is hosting the Recovery Festival on 12 and 13 March to encourage and inspire employers and businesses to work with people in recovery. More information about the Recovery Festival is available here.

Hurrah for Balloons

Dr Marcus Roberts, Director of Membership and Policy, DrugScope

I was recently talking to some colleagues about the outbreak of purple balloons on the website of the National Treatment Agency - you may have seen the photographs of people in parks releasing them to symbolise and celebrate recovery.

Some people I talked to responded sceptically. What did balloon launches have to do with the day-to-day realities of delivering drug and alcohol services - particularly during a period of financial austerity? Weren't these images trivialising the challenges that confront our sector at a time of profound change and not a little anxiety?

Well, yes, the recovery walking is going to ring a bit hollow if the balloons are drifting over treatment services that are struggling for survival. Equally, there is a risk that this kind of affirmation and celebration will become narrowly associated with an exclusivist version of recovery - one that celebrates only a narrow range of outcomes, ignores the significance of 'small steps' and leaves much of the day-to-day work that drug and alcohol services do for individuals, families and communities in the shadows.

Allowing for these caveats, I think that the appearance of balloons on the NTA website is a resonant symbol of what is a momentous and positive step for the development of substance misuse services in our country.

For a start, these images look exactly like something you'd find in campaigning materials for 'mainstream' fields of health and social care (such as heart disease or cancer) and that represents a significant shift in perceptions of our sector and service users.

Fear drove the emergence of drug and alcohol services in the 1980s - specifically, the transmission of HIV/AIDS and other blood borne viruses. Fear drove the expansion of drug treatment from the late 1990s - it was all about crime reduction. Both these phases had a profoundly positive impact. As a result of a harm focussed approach, we now have one of the lowest rates of HIV transmission among injecting drug users in the world, and we should never undervalue our sector's contribution to reducing drug-related crime - which disproportionately impacts on some of the most deprived neighbourhoods and communities.

It is an open question how effective positive visions of reintegration and recovery will be in sustaining investment in drug and alcohol services with the devolution of more control to local decision makers in a period of austerity. I can see why arguments around crime reduction and community safety may be more appealing to elected local politicians than a focus on recovery and social reintegration, particularly in a time of austerity (although recent polling by DrugScope and the UK Drug Policy Commission shows a high level of public support for the provision of high quality drug and alcohol services on health and social grounds).

Be this as it may, it is no small thing that politicians are now talking more about recovery and reintegration and less about disease and crime. Perhaps for the first time - beginning under New Labour and continuing under the current government - we are organising our practice and thinking about drug and alcohol treatment increasingly around a concept ('recovery') which is about hope, not fear.

This article first appeared in DrugScope’s Members Briefing. For information about becoming a DrugScope member visit here.

Seen but not heard – young people’s treatment issues

In June I spoke on young people’s treatment at the Drugs and Alcohol Today conference. It had been a while since I’d focused on young people’s issues. The new treatment agenda has been built around a vision of recovery that is more relevant to adults (for example, substitute prescribing and abstinence). It is this agenda to which a lot of DrugScope’s own policy work has been responding. I’d not registered some government initiatives, notably the Department for Education’s Positive for Youth programme, including a recently published ‘discussion paper’ on Preventing youth crime and substance misuse. Although, to be fair, it is not exactly prominent on the DfE website and some colleagues in children’s charities were not aware of it either.

In February 2010, we published Young people’s drug and alcohol treatment at the crossroads. Many of its recommendations are still pertinent. For example, we called on government to monitor the impact of funding changes on young people’s services with a focus on local variation; we also made the case for a national policy framework for young adults. But, equally, a lot has changed since then. The Department for Children, Schools and Families is no longer with us (and perceptions are that the Department for Education has a narrower policy focus), Every Child Matters is effectively gone and Public Service Agreements (PSAs) most definitely are. Above all, we are seeing local authority budgets being squeezed to an extent that was not envisaged then, along with a strong emphasis on localism and reducing the involvement of central government.

In December, the London Drug and Alcohol Network (LDAN), part of DrugScope, conducted a survey of young people’s treatment providers. We spoke to 18 London service providers; only three said their current funding situation was safe, and many anticipated substantial cuts. An article in the latest issue of DrugScope’s Druglink magazine shows that this issue has not gone away. Addaction have told DrugScope that some local authorities have imposed funding cuts on their young people’s services of up to 50 per cent.

It’s not all doom and gloom. A lot of the work young people’s services do could fit well with a more public health oriented approach to drug and alcohol issues, when treatment budgets are transferred to the new public health service and local Directors of Public Health. Concerns that the NTA has backed away from young people’s services may partly reflect the fact that much of what those services deliver is not treatment in the normal (or narrow) sense of that word; in financially austere times, it is perhaps understandable that an agency with a strong treatment focus would reconsider that investment. For better or worse, public health has a broader scope. There is also specific provision in the 2010 Drug Strategy for Directors of Public Health and Directors of Children Services to work together, pooling public health and early intervention budgets.

But this is a critical time for the development – indeed survival – of young people’s services. DrugScope will soon be meeting officials in the Department for Education as well as with colleagues at the National Children’s Bureau to ensure that the pressure is maintained. A clear and compelling narrative on young people’s services is currently lacking from government. Nor does there seem to be any mechanism for monitoring what is actually happening to these services on the ground. With the lives of some very vulnerable young people at stake, this cannot simply be a local matter for local people – not least, because with DfE estimates showing that £1 spent on young people’s treatment saves between £5 and £8 in subsequent costs, this is an issue with profound economic and social implications for us all.

Young People’s Drug and Alcohol Treatment at the Crossroads is available at: http://tiny.cc/YP-crossroads

Dr Marcus Roberts, Director of Policy and Membership