PHE's Duncan Selbie gives evidence to the Public Accounts Commitee

By Richard Clifton

Almost two years ago, Public Health England (PHE) began operating with a mission to improve wellbeing and reduce health inequalities across the country. £2.7 billion of ring-fenced grants were given to local authorities in 2013/14 to improve public health, including the provision of drug and alcohol treatment and related interventions. The National Audit Office (NAO) produced a report in December 2014 evaluating whether intended outcomes and value for money were likely to be achieved. 

On the 20^th January, the chief executive of PHE, Duncan Selbie, and three others (Dr Felicity Harvey from the Department of Health, Michael Brodie from PHE and Dr Janet Atherton from the Association of Directors of Public Health - ADPH) were called to give evidence to the Public Accounts Committee. DrugScope provided a short briefing to the Committee ahead of the evidence session, focusing on key findings from the forthcoming State of the Sector 2014-15 report and emphasising the breadth and depth of the contribution made to improved public health by the drug/alcohol treatment sector.

The committee voiced concerns about the allocation of public health resources. The committee cited a survey conducted by the British Medical Association (BMA) which suggested that some public health funding had been diverted to support services – not necessarily public health services as usually understood - that would otherwise have faced cuts due to reductions in local authority revenue funding. Margaret Hodge argued that this could potentially lead to a lost opportunity to improve public health.

 Duncan Selbie insisted that the grants were not substitutes for general revenue funding, but that local authorities had flexibility to spend money where it was most required and the allocations were best decided at a local level. Importance was placed on authorities using public health grants to achieve beneficial outcomes at a local level and assessed against local need. There is a mandate for an equitable service, but services should be prioritised based on the needs of individual areas.

Witnesses were asked to explain PHE’s position in relation to NHS England, local authorities and the Department of Health. The committee focussed on a number of different aspects throughout the session: how PHE can work to influence local decisions; how it can influence national allocations, and around the role of mandation in ensuring the effective and universal delivery of services and interventions.

The committee also raised the matter of the ring fence around the public health grant. Having already expressed concerns about its porosity, members were keen to seek views on the future of the ring fence, given that is currently only guaranteed to be in place until the end of 2015-16. Although Selbie has previously called for the ring fence to remain in place beyond 2015-16, on this occasion the consensus among witnesses was that it was a matter for an incoming government.

Selbie argued that health and wellbeing should not be solely conflated with the NHS; and that public health must be considered within the wider context of both economic and environmental issues. In his view, economic prosperity was the biggest health driver and Margaret Hodge agreed that employment, education and housing are all important. However, the committee was keen to focus on areas PHE directly control and witnesses were asked about PHE’s influence at both a local and national level.

Drug and alcohol misuse initiatives receive a third of the public health budget, and so were discussed in a number of contexts during the select committee. While not being included as prescribed functions for local authorities, there are grant conditions in place for substance misuse – a matter that was of some interest to David Burrowes MP, who co-chairs the APPG on Complex Needs and Dual Diagnosis with Lord (Victor) Adebowale of Turning Point. Selbie stated that treatment for substance misuse was not included as a prescribed function due to the variation in need across different authorities and that prioritisation must therefore be local. Referring again to the NAO report, Margaret Hodge observed that when less funding is allocated to drug and alcohol misuse, outcomes are worse.

There was discussion about using the health premium to reward local authorities producing successful results in public health, for which drug treatment is the only national indicator. Like the grant condition, the health premium is new in 2015-16  and is seen as one of the key mechanisms to incentivise and maintain investment in treatment.. The committee expressed concern that the health premium, limited to £5m nationally, might offer only a modest incentive to improve outcomes. Dr Harvey agreed with the importance of an incentive programme and stated the premiums available would increase after a spending review.

Selbie was especially passionate about plain packaging for cigarettes and minimum-unit pricing for alcohol, discussing his desire for a tobacco-free country in the future. He stated that PHE fully support measures to reduce demand for and harm from the two substances due to compelling evidence, and it is down to parliament to pass laws and garner support for harm reduction measures.

As 2013/14 was the first full year of PHE, it was too early to identify if public health outcomes were improving, subsequent years should yield more meaningful data to compare against the baseline. The Public Health Outcomes Framework was acknowledged as a key development in this area. Other examples of effective interventions were provided: PHE’s emergency MMR catch-up vaccinations led to a reduction in the number of measles cases from 673 in the first quarter of 2013 to 70 in the same period of 2014. The ‘Stoptober’ smoking cessation campaign, designed and supported by PHE was successful as well, with a University College evaluation finding it to be cost effective and that it had saved 10,000 years of life.

Half the picture – beyond drug overdose as a cause of death in opioid using people

The big rise in heroin and other opioid drug poisonings that the ONS reported last year has been real focus of concern amongst service providers, policy makers and anyone who cares about the lives of vulnerable people.

But new research from the University of Manchester suggests that while overdoses in opioid users remains the largest cause of death (43%) there are other causes which providers, commissioners and policy makers need to be conscious of particularly amongst older drug users.

Dr Tim Millar who led the research says,

“It is apparent that older users of opioids are one of the most vulnerable groups in society.”

Looking at the paper it’s easy to see why.

Bite-sized Briefing - Nations apart? Experience of single homeless people across Great Britain

As part of the support we offer our members DrugScope's policy team send out a monthly round-up and précis 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 January.

A new report from the homelessness charity Crisis provides a profile of the single homeless population in Great Britain.

It draws on Freedom of Information requests to local authorities, a survey of 480 single homeless people across 17 local authorities, as well as detailed follow-up interviews.

Key findings from the survey results include:

• 48% of homeless people have faced drug dependency and 46% alcohol dependency at some point in their lives (pp. 11-12)
• People are more likely to have multiple support needs if they have experienced several homeless experiences (p. 28)
• The proportion of homeless people experiencing alcohol dependency increases steadily with age, while drug dependency is consistently high between the ages of 21 and 50 (p. 14)

The in-depth interviews also provide evidence that:

• Where people become homeless when asked to leave accommodation by friends or family, this often follows a “lengthy period of difficulty revolving around their substance misuse” (p. 24)
• “Where positive support provision was reported it generally related to provision by the third sector and particularly those involved in addressing substance misuse issues” (p. 44)

Read the full report

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

"I might go back to knitting after all" (or: Why innovation isn't always the answer)

I was in Westminster this morning for a speech by the incoming Minister for Civil Society, Rob Wilson MP. Charity bosses will have been watching with interest – partly because these are challenging times, but perhaps more because of a handful of tone-deaf comments his predecessor made about the role of charities in public life. Such is politics.

Charities have ability to tackle disadvantage - Gov needs to make sure they're supported, @RobWilson_RDG pic.twitter.com/Bkpqu1dGsl
— CentreSocialJustice (@csjthinktank) January 22, 2015

No such provocation from Wilson, who – in a detailed if unremarkable speech – set out his stall. What the third sector needs, he argued, is support for innovative organisations to grow (more on that in a second); better opportunities for charities and social enterprises to bid for public sector contracts; and more action to encourage public and corporate giving.

Shadow Minister Lisa Nandy and others picked up on Wilson’s reference to a ‘bigger society’ – but this didn’t strike me as much more than a rhetorical flourish. What was more noticeable was his – and the other panellists – repeated stress on ‘innovation’. I’m never exactly sure what people mean by this, but here I took it be “finding new ways of solving old problems”.

On the face of it, it’s difficult to argue with that – particularly when some of the old ways aren’t that sustainable. Over recent years, the Cabinet Office has introduced initiatives like the Social Action Fund, a joint venture with NESTA, designed to support new ideas that can grow bigger, or ‘scale’.

There’s no doubt that this money is welcome to those receiving it, but where does such a focus leave those charities that don’t particularly want to tear up their existing model, or grow beyond the area they already work in? Many highly effective organisations – especially in the drug and alcohol sector – have a long track record and are highly attuned to local need.

When I asked the Minister about this, he replied that the Social Value Act – currently under review – ought to help smaller organisations to win public sector commissions. (The review is welcome: I took part in a round-table for it organised by NCVO last November, and my impression was that there’s little evidence of the Act playing this role so far.)

He also said, though, that successful charities should be expected to scale to help more people. This was challenged by the other panellists – Andrew Barnett from the Calouste Gulbenkian Foundation and Danny Kruger from Only connect – who argued that staying small should be a viable option. Wilson clarified he didn’t expect all charities to grow beyond their local area, but his slightly rattled tone suggested tension.

It’s easy to understand why politicians and policymakers – not to mention many leaders in the sector – want new ideas and big ambitions: they’re facing real challenges and lack money to throw at them. But venture out of Westminster and many small charities aren’t interested in getting bigger: they want to secure the funding they already have (and fear they may lose).

Last week, at DrugScope’s regular forum of CEOs and senior managers from drug and alcohol services, many expressed concern about the pressures on their organisations to expand rapidly or merge in order to remain competitive. In particular, there’s growing evidence that smaller substance misuse organisations are disappearing without trace, as their contracts are taken over by larger providers.

Of course, not all small providers are effective, and often charities grow or merge because it makes sense. But when contracts change hands it’s expensive, puts staff under stress and can disrupt services – which poses big risks for people with severe drug dependency. One question is how we can encourage better subcontracting by large providers, allowing smaller organisations to stay put when they’re doing a good job.

There’s a place for experimentation and growth in all charities, but to imagine these can or should be the driving principles for everything they do strikes me as misguided. I wonder if the efforts of the Minister and his officials might be equally well directed at improving life for organisations who don’t want to be innovative or huge – just effective.

Putting numbers to faces: a new map of substance misuse, homelessness and offending in England

New research released today

Statistics can be a limited and limiting way to understand social issues. When we focus on how many people are affected by a problem, or how much the government spends on tackling it, we start to see numbers instead of people. The opposite is also true, though: without statistical evidence, it’s hard to understand the scale of a problem.

For instance, we know that a small but significant number of people facing serious problems in their lives bounce between different kinds of support – drug and alcohol treatment, supported housing, mental health services, and sometimes prison.

However, because these services don’t share information at a national level, it’s hard to know where these individuals’ issues overlap and interact. DrugScope is one of four members of the Making Every Adult Matter coalition, which is committed to understanding and improving their lives, not least through Voices from the Frontline, the project I’m leading. What we’ve lacked, though, is solid data on the national picture – until now.

Pioneering new research from Heriot-Watt University, supported by the LankellyChase Foundation, has found that over 250,000 people in England experience problems with homelessness, substance misuse and offending in some combination. A smaller subset, estimated at 58,000 people, experience all three at the same time.

The research team spent several years analysing multiple official datasets – including the National Drug Treatment Monitoring System (NDTMS) – and building a composite picture. Their report out today, Hard Edges, provides the most detailed data we have yet on the extent and nature of severe and multiple disadvantage in England.

One thing is clearer than ever before from their findings: substance misuse features in a majority of people’s experiences of complex needs. Their analysis indicates that at least 190,000 people with a substance misuse issue also have problems with homelessness and/or offending: this is almost exactly the same number who have a substance misuse problem without these complicating factors.

This diagram estimates the number of people in England experiencing each kind of need, and how they overlap

It’s worth noting that these figures only cover those in treatment – the authors’ estimate including who are receiving no support for a drug or alcohol issues is even higher.

What’s more, the research cements what we already know about the strong link between substance misuse and mental health problems. People with a drug or alcohol problem who are not also homeless or offenders have the highest prevalence (58%) of mental health problems in the study.  And those who are homeless and/or offenders are much more likely to have a mental health problem if they also misuse drugs or alcohol.

The report also provides a useful corrective to commonplace assumptions. Often, when we think of the most vulnerable in society, we focus on single, homeless men with no family connections. However, through an analysis of NDTMS data, the researchers show that of those with the most complex needs – the 58,000 people who have experience of homelessness, substance misuse and offending together – over 60% either live with children or have ongoing contact with them.

This echoes what we've heard from our Voices from the Frontline: for many people with complex needs, particularly women, the fear of losing access to children looms large. These findings also give us cause to revisit the Advisory Committee on the Misuse of Drugs’ 2003 recommendations, which set out the benefits to children of their parents receiving effective drug treatment.

More widely, what should the substance misuse sector take from this important research? First and foremost, the challenge it poses cannot be tackled by the substance misuse sector working alone. Better mental health, access to housing and effective offender rehabilitation must all figure in our response to complex needs.

All the same, any response must continue to include high-quality treatment for people with drug and alcohol problems. This treatment needs be made accessible to those who, because of the other problems they experience, cannot or will not access services through traditional routes.  One model is provided by the MEAM Approach, which focuses on cross-sector partnership and having dedicated co-ordinators for people with multiple needs.

The findings in this report will not come as a surprise to substance misuse professionals - but understanding the scale of the challenge can help us make the case for better care.

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

Drugs and Prison - Statistics from the last year

This weekend there were reports in the media about the increased number of drugs being found in prisons.

This echoes findings in DrugScope's Street Drug Survey, published last week, where we reported that many respondents were finding that synthetic cannabinoids were readily available in prisons and many people referred into services from jails came out with dangerous levels of use of the drugs.

One drug worker said that inmates at a Liverpool prison had become so used to emergency services being called out when people collapsed after taking Black Mamba that ambulances are now known as ‘the Mambalance’.

The last annual report from the HMI for prisons found that around 26% of new arrivals at prison had substance misuse and 19% had alcohol misuse needs. The report makes a number of useful points about substance misuse services in prison:

• Prisons continued to focus on recovery working, which was appropriate, usually with active peer support and service user engagement.
• A quarter of inspected prisons were not focused enough on the needs of prisoners with alcohol problems.
• In a minority of services, recovery working was undermined by enforced reduction or inflexible prescribing, which did not adhere to best practice guidelines.
• Prison substance misuse services offered psychosocial support to prisoners and clinical management of opiate substitution therapy. However, full psychosocial support was not available in a quarter of services and prisoners’ needs were not met.
• Clinical management in most prisons was flexible and catered to individual need. However, some options were limited by the refusal of the prison or SMS provider to prescribe buprenorphine, which was contrary to national guidance.

DrugScope will have more to say about prison drug and alcohol services as part of our State of the Sector work.

The following slides are compilation of the statistics that we've seen over the last year which helps describe some of what is going on about drugs and prisons. 



Update - Channel 4 have uncovered some new information through social media accounts of current prisoners:

 

10 Interesting Things about Alcohol and Other Drugs (January 2015)

We scour the data on alcohol and other drugs and here are 10 things we found in the last month that might interest you, including:

• The number of high risk drug users, 
• Police estimates of the cost and purity of drugs, 
• Trends in property crime, and how drug services may have contributed to it's decline
• Numbers in treatment in Wales, 
• Benefit claimants with drug problems in Scotland (and alcohol problems across the UK), 
• Detection of drugs in prison, and 
• The support needs of single homeless people

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).

Briefing - Mental health and substance misuse

DrugScope has produced this briefing ahead of a debate on mental health being held in the House of Lords today.

There is a close relationship between mental ill health and problems with drugs and alcohol.
Where these issues co-exist (often referred to as ‘dual diagnosis’) people experience poorer outcomes – including high rates of relapse, hospitalisation and completed suicide.

A 2002 study found that:

• 75% of users of drug and 85% of alcohol services experienced mental health problems
• Conversely, 44% of mental health service users reported drug use or harmful alcohol use
• 38% of drug users with a psychiatric disorder were receiving no treatment for it

The Department of Health issued guidance that year establishing that mental health services should lead on providing integrated care, working closely with substance misuse services to establish appropriate processes and training. Progress to date has been limited and inconsistent.

Through its member organisations on the frontline, DrugScope has learned that:

• People are frequently denied access to mental health services on the grounds that their substance use is the cause of their mental ill health or will make treatment impossible
• Raised thresholds for statutory mental health services often mean that people are unable to access mental health care and support until they are close to or actually in crisis
• People experiencing a mental health crisis while intoxicated are often excluded from health-based ‘places of safety’, which may result in being placed in a police cell
• People with drug and alcohol problems have struggled to get appropriate support through the Improving Access to Psychological Therapy (IAPT) programme
• Drug/alcohol treatment providers have repeatedly voiced concern about their clients’ access to appropriate mental health support, and see this as worsening

This is of concern given that a number of international studies suggest that substance misuse can account for the increased risk of violence amongst those accessing mental health services.

What’s more, a recent investigation by the Lancet highlighted concern about adequate funding and training for addiction psychiatrists.

There are specific issues in the prison population, where 70% of prisoners suffer from two or more psychiatric disorders with 75% experiencing dual diagnosis. Lord Bradley’s 2009 report found services are organised in a way that ‘positively disadvantages’ this group. These concerns were again highlighted in Lord Patel's report on drug related crime and offender rehabilitation.

Reviews of the use of Section 135 and 136 of the Mental Health Act have highlighted the problem of intoxication in assessing the mental health of those believed to need a 'place of safety'. In a survey carried out by the Care Quality Commission about half of the providers said that people who were intoxicated would be excluded from the places of safety in their local area. Similar findings are reported by the Centre for Mental Health who say:

This issue of intoxication was a problem for most areas, and some emergency departments (EDs) and most 136 suites would reportedly not accept a person whom they deemed too incapacitated to assess.

Recently, there have been some positive developments:

• The Department of Health is currently engaging with this issue, which is, for example, highlighted in the 'Mental Health Crisis Care Concordat'. This work includes the development of tools and resources to support practitioners and a review of the 2002 guidance on dual diagnosis
• The introduction of Health and Wellbeing Boards provides an opportunity to join up mental health and substance misuse care (which are currently commissioned separately)
• The continued roll-out of the Liaison and Diversion schemes will place mental health professionals in police stations and courts, covering half the population from April 2015. These have been particularly championed by Lord Bradley, who observes in his report that “no approach to diverting offenders with mental health problems from prison and/or the criminal justice system would be effective unless it addressed drug and alcohol misuse”.
• The government’s review of the operation of sections 135 and 136 of the Mental Health Act 1983 has made constructive recommendations on health-based places of safety

While promising, it is not sure that all of these developments will be sustainable and provide the systemic change needed. This is particularly difficult given the division of funding at a local level – with separate budgets for mental health through Clinical Commissioning Groups and substance misuse through Public Health allocations.

It is vital that the opportunities we have to improve support for this particularly vulnerable group are not missed.

Further reading on this topic on DrugScope's website.

Download this briefing as a PDF from here.

6 things we've learnt about young people in substance misuse services in England in 2013/14

Public Health England have published their annual report on young people who accessed specialist substance misuse services in England in 2013-14.

Here are six things I took from the report:

1. The numbers in treatment (19 thousand in 2013-14) have been falling since 2008-09, but are still higher than a decade ago.
2. Most were over 15 years old, but 1 in 5 were younger.
3. Almost half of referrals come from two sources - Youth Offending Teams and mainstream schools.
4. Cannabis and alcohol remain the two most important substances treated for this age group, but fewer and fewer are presenting with alcohol problems.
5. Most young people got a psychosocial intervention and three quarters were in treatment for less than 26 weeks.
6. Substance misuse was likely to be one of a range of problems for the people who accessed these services.