Wednesday, 22 October 2014

Is an ounce of prevention still worth a pound of cure?

Andrew Brown, Director of Policy Influence and Engagement offers some reflections on the 2014 annual conference of the European Society of Prevention Research

The European Society for Prevention Research (EUSPR) brings together researchers and practitioners from across Europe across a range of topics including substance use, obesity, criminal justice and mental health.  Last week 180 members and delegates from across the continent attended the society’s annual conference to listen and debate the economics of prevention.

At the heart of this year's conference, at least for me, has been a question of how prevention science works to influence policy.

A number of keynote speakers raised the question of why strongly evidenced interventions remain unused while ineffective prevention continues to have the confidence of policy makers. The answers seemed to focus around three things:

·         Public support for the least evidenced and hostility to interventions that may challenge their existing behaviours,
·         Other actors working actively against the introduction of those policies, and
·         The weakness of prevention science in developing values messages that work with the grain of evidence.

But I also heard researchers and practitioners banding together to learn from approaches that were having traction. Whether that was the Social Research Unit in the UK working closely with the Washington State Institute for Public Policy (WISPP) to build robust benefit & cost models for particular interventions, or by developing international standards for prevention under the wing of either the UN or EMCDDA. I also heard presentations about designing systems that worked from the bottom up, including an impressive attempt to professionalise the workforce in school prevention coming out of the Czech Republic and a group that are in the process of designing a Universal Prevention Curriculum.

Monday, 13 October 2014

October's 10 Interesting Things About Alcohol and Other Drugs You Might Have Missed

Posted by Andrew Brown, Director of Policy Influence and Engagement

These slides are a way of capturing some of the interesting information about alcohol and other drugs that I come across in my reading.

As you'll see the ones below include data on commissioners plans to reduce spending on services, injecting drug users and HIV, smoking prevalence, proportion of new Europol cases relating to drugs, the time spent on OST, regional variation on emergency hospital admissions for alcohol related liver disease, prisoners use of substances and their relationship to the crimes committed, numbers accessing domestic violence refuges, single homeless people's use of drugs and alcohol.

It should be clear where I've sourced the information from but if not (and you'd like to know) then do get in touch.

It is also worth saying that if there are any errors in the presentation they are almost certainly mine rather than the original authors.

Tuesday, 7 October 2014

Making the case for drug and alcohol services in new times

A blog by Marcus Roberts, Chief Executive of DrugScope
Today DrugScope has launched a new resource called Making the case, as part of our work on behalf of the Recovery Partnership. It's a guide and toolkit to help our members and supporters to make the case for drug and alcohol services at local level - whether that's organising a service visit for elected councillors, marshalling the best evidence to present to local commissioners or working with local media to get positive stories about treatment and recovery out there.  

The days when the political energies of our sector could be focussed mainly on Westminster and Whitehall are gone. The aftermath of the Scottish referendum promises new adventures for devolution and regionalism. This is the latest phase in an emergent politics of 'localism', now de rigeur across the political spectrum (witness, for example, the recent IPPR Condition of Britain report, which is influential within the Labour Party). 

From 2001 to April 2013 substance misuse was the responsibility of a special health authority with a 'ring fenced' budget of around half a billion pounds, topped up by local investment. Both the National Treatment Agency and pooled treatment budget have since been absorbed into 'public health', a migration that has created pressures for both the migrants (pounds and people) and the new host culture (historically inclined to 'prevention' and 'whole populations' - but also with a strong track record of saving and improving lives through 'harm reduction').

The economic and political context for this transition is bracing. The Local Government Association (LGA) calculates that central government funding for councils will fall by 40 per cent over the life time of this parliament (2010-2015). The former LGA chairman, Sir Merrick Cockell, has described 2015-16 as a crunch year, saying 'we expect some councils to be placed in a position where they do not have the money they need to meet their statutory obligations'.

Against this background, an LGA press release on Novel Psychoactive Substances recently expressed concern that 30% of local public health budgets were spent on drug and alcohol services, and hoped for a 'clamp down' on this 'staggering sum'. This shows how our sector might be viewed through the other end of the telescope, and how attractive the budget we have brought into public health is looking to others right now. When Simon Stevens, NHS Chief Executive, declared at Public Health England's Annual Conference that he feared we are 'sleepwalking into the worst public health emergency for at least three decades', he was calling for a radical five year plan to tackle obesity. Priorities are shifting.

Meanwhile recent headlines warn of an NHS funding gap of £2 billion coupled with worries of a 'demographic time bomb' being primed by the ageing population.

The challenges are formidable, but there are positives. DrugScope's State of the Sector 2013 found no evidence of widespread disinvestment in the early months following the changes introduced in April that year. At regional events with our members and other stakeholders the message appeared to be that drug and alcohol services were well-established, with a hard won appreciation of their contribution embedded in local systems and structures ... but also real anxieties about the future.

Last Friday, Public Health England and the Association of Directors of Public Health published a review of the drug and alcohol commissioning intentions of local authorities in 2014-15 and beyond. While the review found ‘little intention to simply disinvest in services’, it reported that over a third of councils were planning to change or reduce funding in the two financial years 2014-15 and 2015-16 (see my blog with Andrew Brown for a summary and analysis).

Our 2014 State of the Sector survey is now 'in the field', with other indications from our members that a significant number of local authorities are investing less in substance misuse services or planning to do so... And recall the LGA's warnings about pressures on local authority budgets coming to a head in 2015-16. The mantra that we hear is 'more for less' and the challenge is to deliver more efficiently without compromising on access or quality. This is a sector with a history of innovation, creativity and resilience and many of our members are actively taking up this challenge… but this is only achievable up to a point.

So how do we ‘make the case’ locally? Let me pick out three key messages.

Firstly, in one of the strongest episodes of the US television series The West Wing, Mrs Landingham is trying to persuade a teenage Jed Bartlett – later to be the US President – to take up the cause of unequal pay for women in the New Hampshire school where his father is the headmaster. Establishing a theme of the Bartlett presidency, he tells her ‘if you want to convince me of something, show me numbers’. Numbers influence decisions. The equation that £1 on drug treatment = £2.50 saved in subsequent costs had an important role in securing the investment that fuelled the expansion of our sector (another example is the major investment in psychological therapies secured by the Layard report on depression, which was, significantly, the work of the Centre for Economic Performance at LSE). We have some good data and research to work with, and some good tools to help us to use it to best effect, including those launched by PHE last week.

Secondly, Gerard Lemos once said to me that ‘the impact of any research study is inversely proportionate to sample size’. By implication, the most influential ‘research’ has a sample of one. The observation was tongue in cheek, but it highlights the importance of human stories in winning hearts and minds. We’ve all been at conferences where the personal testimony of service users has cut through a long day of policy analysis, graphs and statistics. Similarly, getting local officials and representatives along to a service brings home that it is not just an address, a set of interventions, outcome data and a balance sheet, but a building with skilled and dedicated people in it working to make a difference, and a community resource in its own right.

Thirdly, we are one of many sectors facing similar challenges in the current financial environment. The people that we are seeking to influence have headaches of their own: seeking to balance competing demands and priorities, balance the books and manage funding cuts … all with local accountability and scrutiny, and statutory obligations to worry about too. It is important to engage constructively in this environment, look for opportunities for partnership and offer solutions where possible, while giving clear messages about the risks and threats. 

DrugScope has taken a particular interest in developing partnerships with other sectors in a way that has the potential both to cut costs and improve outcomes for service users and their communities. We are doing this, for example, in our work with Clinks, Homeless Link and Mind as part of the Making Every Adult Matter coalition on multiple needs. We are currently working closely with colleagues in mental health, building on the work we did with the Centre for Mental Health on the potential to commission for recovery across substance misuse and mental health. Our sector is also showing how to effectively mobilise the natural resources that are available in local communities – including, of course, the assets and resources of service users, people in recovery and the networks and communities they have created. This is an area where DrugScope has worked closely with the Royal Society of Arts to support their work on user-centred recovery and connected communities.

Looking for solutions in a tight financial environment can spur innovation, but it also creates significant risks. For example, the assets of service users and the dynamism of community networks and initiatives have a critical role to play. It is important, however, to ensure that this contribution is appropriately supported (for example, with funding for development and ensuring that there is support for those taking on roles as ‘recovery champions’ and ‘peer mentors’, an issue my colleague Harry Shapiro took up in the Druglink article ‘Walking the line’). In addition, this augments and cannot replace the contribution of specialist staff with other skills and qualifications. The wider danger is that the pressure of the times fuel an unintended ‘race to the bottom’ and cost cutting compromises quality.

To conclude on a positive note, while ‘stigma’ is an issue and a challenge, the public may be more sympathetic than is often assumed. A DrugScope/ICM poll conducted in 2009 found that nine in ten people agreed that ‘people who have become addicted to drugs need help and support to get their lives back on track’ and over three quarters said that investment in treatment was ‘a sensible use of government money’. One in five had direct or indirect experience of drug addiction (and this figure would be significantly increased if alcohol had been included).

None of this is to underestimate the challenges – a phrase of the Italian socialist Antonio Gramsci seems apt: ‘pessimism of the intellect, optimism of the will’.

I hope you find Making the Case a valuable resource in supporting you to influence local people, opinion formers and decision makers. You can also support us to ‘make the case’ by completing our State of the Sector 2014 survey if you are a service manager, and by joining us as a member if you are not with us already.

Monday, 6 October 2014

Review of Drug and Alcohol Commissioning

Posted by Marcus Roberts, Chief Executive and Andrew Brown, Director of Policy Influence and Engagement.

What is the distinction between ‘disinvesting’ and ‘simply disinvesting’?

The question arises as an official review of drug and alcohol commissioning intentions, published by Public Health England (PHE) and the Association of Directors of Public Health (ADPH) concludes that ‘there is little intention to simply disinvest in services’, and ‘if anything, there seems to be an element of trying to protect levels of investment while improving services’. The review was based on structured interviews between PHE Centres and Directors of Public Health, with input from DrugScope based on our State of the Sector 2013 (SOS 2013) survey.

Does the review suggest that there will be disinvestment in the sense that less money is or will be available for treatment services than before?

Friday, 3 October 2014

Pills & Powders, Pleasure or Pain

Posted by Andrew Brown, Director of Policy Influence and Engagement.

On the 24th September the London Drug and Alcohol Policy Forum held a seminar focusing on new and emerging drugs, the current understanding of what is out there, how some users appear to be acquiring them, the sorts of harms they are experiencing and how services might respond.

The following are the notes I made of the contributions of the three panelists: John Ramsey, Adam Winstock and Owen Bowden Jones.

Wednesday, 1 October 2014

Benefit cards proposal raises concerns and questions while offering few answers

At the Conservative Party Conference this week, Iain Duncan Smith, the Secretary of State for Work and Pensions, pledged to introduce pre-paid benefit ‘smart cards’ for social security claimants affected by ‘drug or alcohol addiction, even problem debt, or more’. The immediate activity will focus on extending and evaluating a relatively small-scale scheme currently operating in North Tyneside. While the emphasis in Duncan Smith’s speech was on parents and family, the scope of the current activity is more broadly around people perceived to have difficulty budgeting.
Several charities, usually in partnership with firms from the financial sector, are developing specialised accounts products to accompany the introduction of Universal Credit. These often involve ‘jam jar’ facilities that ring-fence pots of money for specific bills like rent and many involve voluntarily giving up a degree of financial autonomy, such as agreeing to a waiting period before being able to withdraw large sums of money. These specialised accounts are, or will be, entirely voluntary to take up and are fee-charging. A voluntary benefit card scheme could be seen as analogous to this and, in this sense, as offering what some individuals may want.
However, while the idea of a wider roll-out of benefit smart cards may be at least superficially attractive, the proposal raises a number of concerns.
Anyone with an interest in drug and alcohol misuse, treatment and recovery knows that one of the biggest barriers an individual can face is that of stigma. It can have a detrimental impact socially, economically and is often not just restricted to the individual themselves, but often extends to their family. There is persuasive evidence from places where similar cards have been introduced that presenting a recognised card, particularly at a local shop, possibly in front of friends and neighbours, increases stigma. The Government’s 2010 Drug Strategy places recovery capital and reintegration top and centre: introducing a measure that would instantly make someone stand out as being affected by addiction, problem debt ‘or even more’ seems unlikely to yield dividends in that regard.
Again looking at areas where similar schemes operate, the evidence for their efficacy is unclear. Studies looking at income management schemes in Australia, for example, have highlighted both the unclear evidence and the problem of attribution – that is, that in some cases it’s unclear whether a significant positive change has occurred, and that where a change has, it is difficult to attribute it to one cause among a suite of other interventions aimed at the same cohort. Work around similar schemes in the United States (e.g. the Supplemental Nutrition Assistance Program, often referred to as food stamps) have highlighted concerns around stigma and the frequent inability to purchase necessary but unapproved items.
In addition to concerns of increased stigmatisation and unclear evidence of efficacy, any proposal to roll benefit cards out more widely would need to address a number of questions. These include how to avoid unintended consequences. Any measure that would serve as a disincentive to access treatment for drug and/or alcohol use, or to disclose use or misuse as a barrier to employment at Jobcentre Plus would be highly unwelcome – and we already know that for sensitive subjects such as substance use and homelessness the disincentives (whether actual or perceived) are already so substantial that comparatively few people do disclose, or at least not immediately.
While this measure has so far been talked about as a means of protecting children and families from parents or carers who routinely make suboptimal decisions, there is the question of who would decide whether or not an individual would be eligible for (or potentially compelled to take part in) the scheme, and whether Jobcentre Plus staff (or staff in, say, a local authority) are equipped and trained to come to this decision, which could approach or at least rely on a clinical diagnosis in the case of substance misuse. Separate criteria would presumably be needed for problem debt, and the ‘more’ referred to in Duncan Smith’s speech. 
While clearly some people (whether in receipt of welfare benefits or not) do struggle to budget and measures such as the Local Support Services Framework may turn out to be helpful in supporting people to meet the challenges of Universal Credit in particular, there seems to be a risk with benefit cards of moving from support to paternalism, against the direction of travel of reforms by this and previous governments which have tended to prioritise increasing autonomy and responsibility while focusing support on those most in need. Moving away from groups with particular needs to the wider claimant cohort, there is little evidence to suggest such measures are necessary.
Any government implementing this sort of scheme also has practical issues to consider. Such a scheme may come with a substantial cost, financially and in other resources, if rolled out nationwide. The implementation of the Azure card for asylum seekers was beset by problems on introduction and, some campaigners and stakeholders claim, the failings of the scheme are actually inherent to it rather than related solely to problems of implementation. Some of this may carry across to a wider benefit card scheme. For example, if a scheme is limited to a restricted pool of retailers, it may end up penalising those in remote or dispersed communities or some people with mobility problems. This is before one considers the potential for fraud and abuse.

Given that a genuinely voluntary smart card scheme could be seen as being broadly comparable to the commercial or social enterprise products being developed, what could government consider as an alternative? Positive steps to address the deep disadvantages that lie at the heart of poverty and social exclusion – a commitment given by the government in the Social Justice Strategy – might be a constructive way of doing this. For example, investing in health education, family support, support for young carers and so on might all bring rewards, as would improving the support people receive to help them into employment, thereby providing an exit strategy for people with histories of drug and alcohol use.