Tuesday, 23 December 2014

Atul Gawande's Reith lectures: building a system that cares

On my wintry walks to work these last few weeks, I’ve been enjoying the 2014 Reith lectures. Each year, the BBC invites a distinguished guest to give a series of talks on an issue of public interest. This time, surgeon and writer Dr. Atul Gawande has been discussing medicine and public health. I’m grateful to my colleague George Garrad, who suggested they might be up my street.

Dr. Atul Gawande (photo: CfAP, Creative Commons)

Firstly, if you have any interest in health (and which of us doesn’t?) I really recommend listening to the four lectures. In them, Gawande makes a passionate yet highly methodical case for how we can improve the health care that people receive throughout their lives, across the world.

He blends stories from his professional and personal life, which are often very moving, with political argument in a way that’s entirely absorbing (I occasionally came close to walking into lampposts). And although his focus is on medicine, I think the issues he discusses are of vital importance for the drug and alcohol sector – and especially its approach to complex needs, which is of particular interest to me through my work at DrugScope with the Making Every Adult Matter coalition.

Why the system matters

Gawande’s basic argument, as I understood it, is this: over the last century, we’ve made huge advances in knowledge about the body and how it works. We’ve also developed technology – surgical techniques, medicines – that can help us treat ever more conditions. However, what we haven’t worked out is how to apply this knowledge consistently across every hospital, country and continent. This helps fuel the dramatic health inequalities we see at all of these levels.

In his second lecture, therefore, he focuses on problems with ‘the system’: the interactions between people and organisations that deliver healthcare. As a surgeon, he uses the example of avoidable deaths in the operating theatre and describes work that he and colleagues are doing to introduce simple checklists for basic tasks. A tiny detail like washing your hands takes on huge importance when it’s one of hundreds of tasks that contribute to a successful operation.

Often, Gawande explains, surgeons and other medical professionals resist the idea of following a checklist – until they see the evidence that it saves lives (you can read more about this in a fascinating 2007 New Yorker article that he draws on in his talk). However, where his argument gets really interesting is in the final lecture, where he discusses the limitations of this approach:

“But just because you have a roadmap does not mean anyone is going to follow it. There are barriers to overcome to execute even the simplest step, and those barriers differ from place to place. In one health centre, staff may not wash hands because they don’t know it’s important; in another, because they don’t have sinks or running water in the delivery rooms; and in another, because they simply have not made it their habit and no one cares.
"That last phrase I think is the critical one: if no one cares when someone takes the trouble to do things right, nothing changes. And the overwhelming message to the people who work at the frontlines of care around the world is that no one notices excellence and no one cares. That is the biggest source of burnout and discouragement for health care workers everywhere.”

What this means for drug and alcohol services

I think this insight is crucial to how drug and alcohol services approach treatment for those with the most complex needs. We often hear calls for ‘system change’ – the demand that services should be re-designed to work better together. That’s clearly a valuable goal – but it’s also vitally important that we take into account the human beings on whom services depend, who are often forgotten in the rush to reform and restructure.

At DrugScope’s conference in November, I ran a workshop with drug and alcohol practitioners (some of whom also had personal experience of recovery) on their experiences supporting people with complex needs. One substance misuse worker observed – to universal nods of agreement – that they often felt they were “mopping up” problems that other services weren’t resolving in the way they should.

Their personal commitment to the people they work with meant they were willing to compensate for the failures of the system they worked in. It’s one of the great strengths of our sector that, on the whole, it attracts people who care deeply about the work they do, and the lives of those they support. I think to a great extent, this stems from the high number of practitioners who have personal experience of substance misuse. (Incidentally, it’s one the few weaknesses of the lectures that they don’t do more to explore the role of people using, rather than delivering, healthcare services.)

Dr. Gawande’s insight is that in making a system work, you need to do more than simply find the most efficient solution to a problem. You also need to work from the behaviour of people who care, and find out how to build a system that supports them and encourages others to follow suit.

Too often, when looking to reform health and social care, we begin from the assumption that the system can make people better – when actually, the opposite is true. I actually find that idea rather hopeful, and offer the lectures – which explore these issues in rich detail – as a diversion over what I hope is a restful Christmas and New Year.

Sam Thomas is the programme manager for Voices from the Frontline. Follow @iamsamthomas on Twitter.

Monday, 22 December 2014

Bite-sized Briefing - Public Health England’s grant to local authorities

As part of the support we offer our members DrugScope's policy team send out a monthly round-up and prĂ©cis of reports which we believe are of interest to the field.  The following is offered as an example of the content of our Bite-sized Briefing for December.

The National Audit Office have produced an assessment of whether the new public health grant to local authorities is likely to lead to intended outcomes and achieve value for money.

The report makes clear that despite increases in the overall budget allocated for public health (up by 5.5% in 2013-14) allocations within the overall envelope are changing slowly as local authorities exercise their judgement on local priorities.

They report that in 2013-14 local authorities had budgeted 54.3% of spending on sexual health, drugs and alcohol services; in 2014-15 this proportion had reduced to 52.8%.  They also found:
“between 2010-11 and 2012-13 alcohol-related admissions to hospital increased by more than 6% in 26 local authorities. These 26 local authorities spent on average 6% of their public health spending on alcohol services for adults. This was significantly less than the 9% spent by the 26 local authorities where alcohol-related admissions reduced the most.” 
 Other key messages from the report are:
  • A survey of stakeholders found that three-quarters of respondents have a good working relationship with PHE, although it is generally too early to tell whether public health outcomes are improving. That said, the report points out that PHE prioritised 54 local authority areas for intensive diagnostic and support work to improve recovery and reduce relapse rates leading to a 1.3% increase in recovery rates.
  • The Department of Health has not decided how long the ring-fence for the public health grant will remain in place.
  • There have been limitations in the quality of data, for example, 81 local authorities initially reported not spending anything against 1 or more of the 6 prescribed public health functions, and there are lags of at least 18 months for publishing much of the public health outcomes data.
  • Some stakeholders think PHE should display stronger system leadership.  However, the formal levers available to PHE for securing better public health outcomes are limited and the autonomy of local authorities gives no guarantee that PHE can secure improvements in outcomes (and at £5 million, the health premium risks being too small to bring about significant change).
Download the full report here.

If you would like to join DrugScope you can do so here.

Friday, 19 December 2014

10 (more) things - late December edition

A final set of slides for the year with 10 more things I saw about alcohol and other drugs and which I thought were interesting.

This time including: data on drug deaths as a proportion of all deaths of adults 15 - 43; the use of naloxone by ambulance crews in the East Midlands; substances people said they were dependent on amongst people in police cells in London; seizures of drugs and mobile phones in HMP Durham; victims of criminal exploitation; number of people using residential rehab; cultivation or illegal drugs in Scotland; number of possession and possession with intent to supply offences recorded in Scotland; global narcotic seizures by the Royal Navy; and % changes to the ABV of alcohol between 2011 and 2013.

As always any misinterpretation of the data you spot are down to me (and please do let me know so that I can fix them).

Wednesday, 17 December 2014

StreetLink celebrates its second anniversary

Many happy returns, StreetLink
Prior to joining DrugScope in 2012, much of my working life had been spent in homelessness services of one sort or another. Between the mid-90s and 2010, I worked in hostels, supported housing, outreach and floating support, before spending two years at Homeless Link, the membership organisation for the sector.

Despite getting to know the homelessness sector pretty well during that time, I was sometimes perplexed when faced with rough sleeper outside of work. Identifying the relevant outreach team (having first established that there was an outreach team – many areas don’t have one), finding a contact number or email address and then actually getting through (outreach teams generally work highly unsocial hours) could be time consuming and complex. If I was away from my adopted home turf of London, these difficulties were compounded. I thought at the time that if it was a difficult and time consuming process for me, for someone unfamiliar with the way the system works, what services work with whom, what they might be called and so on, it would be even more daunting, if not impossible.

In December 2012, life was made considerably easier for anyone worried about someone sleeping rough, including rough sleepers themselves. Building on the work of the No Second Night Out London hotline, StreetLink was rolled out across England. Developed and run by Homeless Link and Broadway (now St Mungo’s Broadway) and funded by the Department for Communities and Local Government (DCLG), StreetLink provides a single portal for rough sleepers themselves, members of the public, and members of emergency, health and support services to get connected to outreach teams.

What StreetLink does is in some respects quite simple – it takes referrals (and self-referrals) from anywhere in England and passes that information on to the relevant outreach team or local authority. Instead of having to go through the process of researching provision in any particular locality, StreetLink provides a single phone number, mobile app and website and even offers to let people know – in a general sense – what happened to their referral. In contemporary terms, it ‘hides the wiring’ of what remains a complex patchwork of services and provision spanning around 150 local authorities.

About rough sleeping and homelessness
The relevance for drug and alcohol services is in the number of people they support who have housing problems of one sort or another. Around 10% of people starting new drug treatment journeys in 2013-14 had no fixed abode, with a further 14% having other housing problems. The corresponding figures for those starting new alcohol treatment journeys are 4% and 10% respectively.

As those figures have been pretty constant for some years, it seems plausible that over 10,000 people in contact with drug and alcohol services are actually homeless, with around 40,000 having some other sort of housing problem. Looking at it from the other side, we also know that ‘tri-morbidity’ is commonplace – rough sleepers often have coexisting poor physical health, poor mental health and problems involving substance misuse.

Nationally, over 2,400 people sleep rough on a typical night. This number is based on the street counts conducted in winter and reported by DCLG and represents a continuation of an upward trend visible since 2010, when the street count guidance was changed. In London, the CHAIN database used by all the main outreach teams suggests a corresponding significant increase, with new contacts increasing from 1672 in 2007-08 to 4363 in 2013-14.

These numbers are substantial. Figures recently released by StreetLink show that in the two years it has been operating, almost 9,000 people have used the service and been connected with support, just over a quarter of them self referrals from rough sleepers themselves. Of these, almost 1,700 have been supported into accommodation.

There is a discrepancy between those numbers. Of course, some of the referrals may have been inappropriate for StreetLink; for example, people who are street active (begging or drinking on the street, say) rather than rough sleeping, or people who are already known to services.  Some referrals may have been impossible to find, or may have been reluctant to accept the service offered.

Simply being referred to StreetLink doesn’t itself bring any additional entitlement to accommodation. The ‘priority need’ criteria still apply (everywhere apart from Scotland, although the London Assembly has called for it to be abolished in London too) and the rules around benefits and public funds (subject to frequent toughening and revision where non-UK citizens are concerned) can often serve as barriers to services. With UK nationals making up just under half of the rough sleepers in London, that means that many people find their options very limited.

For many foreign nationals, this might mean access to a reconnection service like the one run by homelessness charity Thames Reach, but little more. For the rest, StreetLink faces challenges in both supply and capacity; Homeless Link suggests that while the number of rough sleepers steadily increases, the services that can support and accommodate them are facing tremendous financial challenges as are the local authorities who play such a crucial role.

How you can help
By way of disclosure, I volunteer for StreetLink and from my experience, many (but by no means all) of the people who make referrals themselves in one way or another work with adults with complex needs – treatment providers, off-duty housing and homelessness workers, members of the emergency services and so on. You may be one of those who have made a referral, but if not, please have a look at StreetLink’s website and save the phone number 0300 500 0914 – the phones are staffed 24 hours a day, 365 days a year.

If you have a smartphone, you can also download the StreetLink app which makes reporting easier and quicker and also contains links to information, statistics and other sources of help. It’s available for Android and iPhone. If you’re working with someone from central or Eastern Europe who might benefit from reconnection, the information on Thames Reach’s Routes Home pages might be of interest, although if they're rough sleeping, StreetLink would be the best first point of contact.

Finally, while StreetLink has a small, dedicated team of paid staff, it also relies heavily on a pool of volunteers. If this might be of interest – and please note that while rewarding, StreetLink is closer to call centre work than the coal face of rough sleeping – you can contact the team at the following address: volunteers@streetlink.org.uk 

By Paul Anders, Senior Policy Officer, DrugScope.

Monday, 15 December 2014

Owen Bowden-Jones: If I had my way the government would...

This is a guest blog from Owen Bowden-Jones. 

Owen is the founder of the Club Drug Clinic, the current Chair of the Faculty of Addictions at the Royal College of Psychiatrists (2010-2014), a Consultant in Addiction Psychiatry, overseeing alcohol and drug services in the borough of Kensington and Chelsea and an Honorary Senior Lecturer at Imperial College in the Division of Brain Science.  Owen is also a Trustee of DrugScope.

Invest where the evidence is most robust.

Develop an inspectorate for scrutiny and oversight of commissioning.

Move commissioning of drug and alcohol specialist services from local authorities to Clinical Commissioning Groups.

For both drug and alcohol problems, increase the focus on young people at early stages of harmful use. Early intervention is well established for most illness management and should become a priority for harmful/dependent drug and alcohol use.

Invest in technology to support recovery. Relapse prevention, motivational enhancement and peer support can all be enhanced with online/mobile telephone interventions.

Review the workforce to ensure that necessary skills are retained within the sector. We are facing a brain drain, particularly for addiction psychiatry, which is bad news for the whole sector.

Tuesday, 9 December 2014

Jan King: If I had my way the government would...

This is a guest blog from Jan King, the Chief Executive of the Angelus Foundation.

We need the government to take positive steps to ensure young people are better informed of the risks to their mental and physical well-being from new psychoactive substances, the so called ‘legal-highs’.

We already have a poor commitment to drugs education in this country and the government needs to ensure that all schools cover some key messages. There has been an understandable trend to schools setting more of their own teaching agenda but this cannot be at the expense of our young people’s future health and well-being.

Compulsory PSHE (Personal Social and Health Education) would be a welcome start and much more proactive means of getting messages to young people. We need well thought out approaches delivered in a range of ways but ideally with young people centre stage saying what works for them.

The emphasis needs to be on equipping them to withstand the myriad of pressures they may face and not rather pointless enforcement messages around potential penalties.

At Angelus we have been visiting schools, universities and festivals showing films of what can happen when people experiment with untested substances with little idea of what they are taking let alone what might be a safe dose, assuming such a thing is possible. When they see the outcomes they are often angry they have not been informed by anyone before that there are new forces at play trying to take advantage of their potential vulnerabilities.

While we are committed to working with young people and their parents so that young people can take informed decisions we need the Government to be taking a much clearer stand on what schools should be doing to stem this pernicious trend.

The Government’s review into NPS goes some way in the right direction but the new Administration will need to ensure that its recommendations are pursued vigorously if we are really to keep our young people safe.

There will be no time to rest on any laurels as we know the industry that knocks out these substances will already be cooking up new ways to get around any changes in the law.

Sunday, 7 December 2014

10 things to know about the number of adults in drug and alcohol treatment in England in 2013-14

Here are 10 things I've found in looking at the data in Public Health England's reports on drug and alcohol treatment in England in 2013-14.
  1. There were 308,118 adults in treatment for drug (193,198) or alcohol (114,920) problems. Almost half (151,859) were starting new treatment journeys (70,930 for drugs and 80,929 for alcohol). 
  2. Amongst those accessing treatment the proportion addressing alcohol problems has increased from 32% in 2008-09 to 37% in 2013-14. 
  3. Across drug and alcohol treatment 71% were male and 84% identified themselves as White British. 
  4. 45% of those exiting treatment for drug problems did so free of dependency, 59% successfully completed alcohol treatment in 2013-14. 
  5. 53% of the estimated number of opiate and crack users (293,879) in England were accessing treatment in 2013-14. 
  6. 18% of the estimated number of dependent drinkers (630,000) in England were accessing treatment in 2013-14 - this compares to one in four in Scotland
  7. Just under half (45%) of those coming into treatment last year were over 40 years (67,952 individuals) - this was particularly true for alcohol where over 60% were over 40. 
  8. The number of people in the drug treatment system who are over 40 years old has doubled since 2005-06 - from 32,406 to 69,806. 
  9. The biggest source of referrals to the treatment system was by those seeking help themselves (43%), 12% of referrals were through GPs (however, the proportion for drug treatment was only 6.6% compared to 17% for alcohol). 
  10. Nearly 10,000 people entering drug and alcohol treatment last year had no fixed abode at the time they started treatment. A further 17,312 were having other significant housing problems (such as staying with friends or family as a short-term guest or residing at a short-term hostel). In total nearly one in five (18.7%) of new entrants were experiencing housing problems.
As always should you spot any errors in the way I've interpreted the data I'd be grateful if you let us know so that I can correct them.

Friday, 5 December 2014

Interesting things about alcohol and other drugs that you may have missed - December 2014

Two sets of slides full of what I hope are interesting pieces of data about alcohol and other drugs that you may have missed this month.


Tuesday, 2 December 2014

Take home naloxone

Stephen Malloy with naloxone
Stephen Malloy with naloxone
CC Image courtesy of  Nigel Brunsdon on Flickr
Andrew Brown, Director of Policy Influence and Engagement on the case for take home naloxone in England

Last year saw a worrying 32% increase in the number of heroin related deaths in England, which may have been reduced had naloxone been more widely available.

Naloxone is a medicine which is licensed for use in the treatment of suspected opiate overdose.  The medicine is already routinely carried and used by paramedics in the UK.  

In 2012 the Advisory Committee for the Misuse of Drugs called on the government to act to make naloxone more widely available, for instance, by providing drug users and family memebers with supplies of the medication, arguing that it is an evidence-based intervention, which can save lives and:
"fits with other measures to promote recovery by encouraging drug users to engage with treatment services, and ultimately, keep them alive until they are in recovery."
Earlier this year the Department of Health responded saying that regulations would be developed by the Medicines Healthcare Products Regulatory Agency (MRHA), and brought into force by October 2015.

In response to the rise in heroin and other opiod related deaths in England a number of organisations including DrugScope have come together to form the Naloxone Action Group for England.  At a summit hosted called by IDHDP and Blenheim CDP we looked at the learning from the national naloxone programmes in Wales and Scotland and at how a Birmingham GP (Judith Yates) has taken action to increase access to the medicine ahead of the MRHA regulations coming into force in October next year.  We heard from service users, drug treatment providers, NHS staff, academic and legal experts and others from across the sector and discussed actions we would want government, local commissioners, practitioners and manufacturers to take to reduce the number of overdose deaths.