DrugScope's closure: thank you for your support

As you may have read, earlier this week DrugScope announced its closure after fifteen years serving the substance misuse sector, and working on behalf of people facing drug and alcohol problems.

This has been a terrifically difficult time for all the staff here, but we have been overwhelmed by the response to the news - both from partners and friends that we know well, but also from many others who have appreciated DrugScope's work over its long history.

We've collected a small sample of these messages, and offer them for what they say about the continuing and vital importance of effective drug and alcohol services and sensible, evidence based drug policy.

From everyone at DrugScope, thank you for your support over the last 15 years, and your good wishes at this sad time. They are much appreciated.

Interesting things about alcohol and other drugs you might have missed - April 2015

One of the things I've enjoyed about being at DrugScope has been ferreting out fascinating information that is out there about our field.

This month the slides include information which suggests:

• Areas with highest levels of need are dis-investing in alcohol services faster than other areas. 
• Many fewer teachers are being trained to deliver health education. 
•  That only very small numbers of under-18s are being treated for cannabis psychosis in hospital (but there's been a rise in the last year).
• That more people with drug and alcohol issues in receipt of ESA are likely to be sanctioned than would be proportional.
• That there are now more people being convicted for drug offences than alcohol ones.

Drug Related Deaths Summit 2015

As we’ve explored previously on this blog, drug users are likely to suffer health inequalities across a range of domains. However, deaths through overdose remain the most important preventable harm for the health and treatment system to address.

Last year’s annual report by the Office for National Statistics on drug-related deaths showed a sharp increase in deaths that were recorded as resulting from drug misuse, and we blogged and commented on this at the time.

The number of deaths rose from 1,492 deaths in 2012 to 1,812 in 2013, a 21% rise and the highest number since 2009.

At the beginning of this year, working with Public Health England and the Local Government Association, DrugScope organised a summit to examine what might be causing the rise and to look at what might be done to reduce overdose deaths in future years.

The attendees included policy makers from across government, commissioners, clinical and service provider leaders, and service user perspectives.

The key messages from the summit were:

• The availability of accurate, timely and easily accessible data is important in order to make the appropriate adjustments to policy and practice in order to reduce drug-related deaths;
• The majority of drug misuse deaths still involve opiates, in particular heroin and methadone;
• Being in contact with a treatment service would appear to be a significant protective factor for drug-related deaths;
• Services and practitioners should pay attention to the elevated risk for those in treatment who are regularly overdosing, are drinking excessively, live alone in temporary accommodation or are homeless, or as a result of smoking-related diseases have compromised respiratory systems;
• Policy makers and commissioners should think about providing timely and accurate alerts to drug users who are not in the treatment system - including drug users who don't use opiates;
• Commissioners and services should look at how they could supply naloxone more widely in the community to ensure those vulnerable to heroin overdose (including those not in treatment), their families, peers and carers are able to access the medicine. 

Download the report here.

Presentations to the summit

A fair chance? Sanctions and vulnerability

This week saw the release of a significant report by the House of Commons Work and Pensions Committee - Benefit sanctions policy beyond the Oakley Review. The report contains a number of welcome recommendations, including that the next government should conduct a broad, independent review of the way sanctions are used plus how vulnerable claimants can be protected and, crucially, identified. DrugScope submitted evidence jointly with Homeless Link – you can find our submission here.

We’ve long been concerned that sanctions put vulnerable people at risk of financial hardship, as my colleague Sam Thomas has blogged about before, and that some proposed changes may increase that risk, as DrugScope’s Director of Policy Andrew Brown recently blogged about. We weren’t able to tell much about people with needs relating to drug and alcohol misuse from the official statistical releases, other than that the number of Employment and Support Allowance (ESA) and Jobseeker’s Allowance (JSA) claimants sanctioned has increased substantially over the last few years. What we know from some other sources gave cause for concern, though.

Several evidence reviews have highlighted the risk of people with vulnerabilities being disproportionately affected by sanctions. For example, this from the Scottish Government:

“The literature suggests that those who are particularly vulnerable to sanctions are also the most disadvantaged. This includes people that lack work experience or who face practical barriers to work, such as not having access to a car; or those with health problems, including drug and alcohol dependencies; and those with mental health difficulties.”

This from the Social Security Advisory Committee, writing about conditionality and Universal Credit:

“The evidence suggests that many vulnerable claimants do not set out to be noncompliant but they often lead chaotic lifestyles, have poor organisational skills and frequently forget the conditions they are supposed to fulfil. A recent study of offender employment services also referred to the chaotic lifestyles of many offenders and their inability to understand the sanctioning regime, and questioned the utility of sanctions as a mechanism for generating behaviour change amongst certain groups.”

The Joseph Rowntree Foundation published an evidence review making similar observations, and the problems faced by vulnerable groups in particular was highlighted by the independent Oakley Review of communication around JSA sanctions, published in 2014.

So far, so worrying. There is additional evidence that illustrates the risk to vulnerable groups. A response by the Department for Work and Pensions (DWP) to a Freedom of Information Request suggests that while ESA claimants with a primary medical condition (PMC) of a mental or behavioural disorder make up around 45% of the ESA caseload, they account for around 60% of ESA sanctions.

Research by academics on behalf of homelessness charity Crisis found that while it was difficult, using administrative data, to make a direct connection between homelessness and the risk of being sanctioned, there was fairly persuasive circumstantial evidence that:

“Homeless people, then, may face a ‘double whammy’: disproportionally sanctioned by virtue of belonging to groups overrepresented in the sanctions statistics (young, male), but also more likely to experience barriers to complying with the new conditionality regime.”

They also pointed to research by Homeless Link which found that sanctioning rates were exceptionally high for homeless people, with people who misuse drugs and/or alcohol at particular risk.

DrugScope’s own State of the Sector 2014-15 found that while some elements of welfare reform had affected more people, no individual reform had had such strongly negative impact than the post-2012 sanctions regime:

Source: DrugScope, State of the Sector 2014-15

ESA, drug and alcohol misuse and sanctions

A picture is emerging, albeit one informed by somewhat peripheral evidence. We were keen to learn more. There are problems with some of the data around drugs, alcohol and benefits. While there is a marker on LMS (DWP’s Jobcentre IT system), it’s used very inconsistently. On the other hand, claimants in the ESA Support Group are effectively excluded from conditionality. That leaves the ESA Work Related Activity Group, or WRAG. As part of the claim and assessment process, claimants are assigned a PMC, which for a small number of claimants, can be alcohol misuse or drug misuse.

We submitted a request to DWP in December, which they responded to this week. The numbers provided are illuminating. Firstly, the number of people with a PMC of drug or alcohol misuse receiving a sanction seems quite volatile:

However, this should be seen in the context of an overall ESA sanctioning rate that is itself volatile:

Source: Dr David Webster, University of Glasgow

There’s not very much one can tell from looking at those two charts. What we have done with the response from DWP sheds a little more light. We have calculated the proportion of ESA WRAG claimants with a PMC of drug/alcohol misuse out of all claimants. We have also calculated the proportion of people with a PMC of drug/alcohol misuse sanctioned out of all people sanctioned, and have then compared the two figures.

Like people with a PMC of a mental or behavioural disorder, it appears that people with a PMC of drug or alcohol misuse are disproportionately likely to be sanctioned, and have been fairly consistently so – the new ESA sanctions regime introduced in late 2012 doesn’t seem to have made a difference as far as the proportion of people being sanctioned is concerned:

Caveats

As alluded to above, there are several limitations to what we’ve done. These include:

-          Not everyone with needs relating to drug and/or alcohol misuse will be recorded as having a PMC of drug or alcohol misuse. For example, an intravenous drug user who has caused themselves nerve damage that limits their mobility may well be recorded as having a different PMC. The same might apply to someone with impaired liver function as a consequence of alcohol misuse, or someone with coexisting mental ill health and substance misuse needs.

-          In the context of the overall number of JSA and ESA sanctions, we’re talking about a relatively small number of people. Seen against almost 900,000 JSA claimants sanctioned between April 2013 and March 2014, the numbers aren’t huge: 8,399 ESA claimants with a PMC of drug/alcohol misuse sanctioned over 6 years, split pretty evenly between drugs and alcohol. That is still a large number of people who will have experienced financial hardship, but due to this and the reason above, we can be certain that we’re only getting part of the picture.

-          Finally, while we have long been concerned that the conditionality and sanctions regime is being used punitively, may not be achieving its stated aims and may actually be counter-productive, the numbers alone don’t tell us anything about how fairly these sanctions have been applied, how proportionate they are, if they comply with policy and guidance and so on.

To conclude

We now have what appears to be some clear evidence that, at least for Employment and Support Allowance claimants in the Work Related Activity Group, people with a primary medical condition of drug and alcohol misuse are at a disproportionate risk of receiving a sanction, much as claimants with a primary medical condition of a mental or behavioural disorder are. Couple that with the findings from DrugScope’s State of the Sector, research by Homeless Link and Crisis and literature reviews by the Social Security Advisory Committee and the Joseph Rowntree Foundation, and a picture emerges of a system that appears to not protect the most vulnerable in society and may, in fact, be placing them at risk of considerable financial hardship.

The Work and Pensions Committee appears to think the same way. Hopefully, whatever the outcome on 7 May, the next government will accept their recommendations and make addressing them a priority.

Posted by Paul Anders

What’s happening to funding for drug and alcohol interventions locally?

Roberta Silva is a Policy and Public Affairs Intern working at DrugScope.  She is currently working on a project looking into local government funding allocations for substance misuse services.  This is the first of a series of occasional posts from Roberta, to update you on the progress of this work.  

Love Money?, photo by Flickr user Rob Jewitt

Since April 2013, there have been significant changes in the commissioning and funding of drug and alcohol treatment services.  The reforms introduced by the Health and Social Care Act 2012 established Health and Wellbeing Boards in every local authority and shifted the responsibility to them to produce Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies (JSNA and JHWS) for every area (see DrugScope’s The Public Health Reforms).

A JSNA is an assessment of the current and likely future health and social care needs of a local area.  They are often lengthy documents and the information from them is used to develop a Joint Health and Wellbeing Strategy (JHWS), which forms the basis of health and care commissioning in local areas.  However, these vary hugely from one authority to another.

There has been lots of talk about changes to funding for drug and alcohol treatment in recent years, but relatively little hard evidence. Although the Department for Communities and Local Government produces actual and projected spend on a range of services twice a year, these figures do not really provide sufficient detail for analysis.  Last month, DrugScope’s State of the Sector 2014-15 revealed a net average reduction of 16.5%, but that was at a service level, which tells us very little about how local systems are being resourced.

This project is an attempt to shed some light on what’s really happening in terms of funding.  It consists of two components. The first is a scan of all 150 or so JHWSs in England, to try to ascertain the inclusion and/or prioritisation of drugs and alcohol. As there’s no standard template – or length – of JHWS, this has involved scanning of each strategy and then assigning the prioritisation given to one of three values for each of adult alcohol interventions, adult drugs interventions and young people’s substance misuse interventions. We should acknowledge that the assignment of prioritisation is inherently subjective – many areas have not marked drugs and/or alcohol explicitly as a priority, but do make a number of references to the issue, for instance referring to substance misuse in the context of the whole population, specialist interventions, the night time economy or a mixture of the three. We’ll consider carefully how best to report these findings.

Bite-sized Briefing - Take-home naloxone for opioid overdose in people who use drugs

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.

Case Study of steps to take to introduce
a take-home naloxone scheme

Public Health England have produced a document giving advice to local authorities and others on promoting the wider availability of the overdose medicine naloxone.

The paper sets out the current position on supplying naloxone saying that it can be prescribed to anyone who is: currently using illicit opiates (such as heroin); receiving an opioid substitution therapy; leaving prison with a history of drug use; those who have previously taken opiates (in order to prevent relapse).  Equally importantly, if the person who has been supplied naloxone agrees then it can also be supplied to family members, carers, peers and friends.  They do warn that:

Regardless of how naloxone is provided locally, information on the risks of overdose and how to respond in an emergency should be available to all those at risk, their carers and families, and staff.

Freedom of Information requests by Release and the National Needle Exchange Forum show that one in three local authorities are currently providing take-home naloxone.

Changes to the regulations which will make it even easier to make naloxone more widely available are being drafted by the Medicines and Healthcare products Regulatory Agency (MHRA) and will come into force in October 2015.  PHE suggest that the new regulations will mean “naloxone is made exempt from prescription only medicine requirements when it is supplied by a drug service commissioned by a local authority or NHS.”

The paper includes steps that local authorities or others interested in making naloxone more widely available may wish to take, based on the experience of Birmingham which has had a take-home scheme since 2012.  There is also: an outline of the issues that need to be covered in training in overdose prevention; advice on recording how naloxone is supplied; and a reminder that naloxone is just one way to reduce drug related deaths.

Download the paper here.

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

What does a good life mean to you?

It might mean having a safe and secure home; forming respectful and trusting relationships; or experiencing new places and activities. In fact, I'd be surprised if at least one of those didn't feature in your answer.

Recently researchers from Revolving Doors Agency asked members of their national service user forum – all of whom have experience of multiple needs, including drug and alcohol misuse – to think about this question.

They produced collages (right, and below) that represented their ideas of a good life, and then talked through them. A report describing the process was published yesterday, and makes for a fascinating read. Looking through it, a few things occurred to me.

Firstly, those basic components of the good life I mentioned earlier are as important to people facing complex situations such as drug dependency as anyone else – and arguably more so.

This should be obvious, but often our public debate treats people with serious problems as if they can only be defined in terms of what's gone wrong. Ask people what they want to achieve, though, and you get a very different response. For instance, one participant said:

“That’s just … what I would like, to be able to, sleeping easy at night, not worrying, security, not worrying, just to be able to feel safe in my own house, not having the door banging in or, yeah bailiffs, no police, no dealers, no owing money, just … happy place."

Secondly, work is a hugely important part of this picture. One person, talking about their job, said: “I respect myself, I feel good cos I’m one of the workers coming home from work and life’s normal.”

This echoes the findings of our project with Making Every Adult Matter, Voices from the Frontline. Many people with experience of multiple needs see meaningful work as a central goal - even if they're some distance from full-time employment.

Finally, it made me think about the role of treatment services. Some people involved in the study felt that an important step towards the life they wanted was ceasing to be dependent on services. However, others recognised the value of the strong, positive relationships that they formed through accessing them.

The recovery movement rightly acknowledges the importance of creating a supportive community within which people can resolve their challenges. Sometimes, though, this comes with strong expectations about the manner in which people need to change their lives, and at what speed.

The report concludes (and for what it's worth, I agree) that as far as possible, someone seeking help must decide for themselves what a better life looks like. That requires a support system that can reconcile professionals' views on what’s most important – reducing drug use, getting a home, getting a job – with people's own personal goals.

(Importantly, it also provides reason to think that coercing people into accessing treatment, as has recently been proposed, is unlikely to help people achieve lasting change.)

It follows from this that the system mustn't put barriers in the way of success. Through our work on Voices from the Frontline, we've seen how the unintended consequences of government policy can hold people back from realising the kind of life they want to lead. This valuable research helps strengthen the case for why that has to change.

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