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

Education Select Committee calls for PHSE to be made statutory

Life Lessons, photo by Flickr user niXerKG

DrugScope welcomes the Education Select Committee’s recommendation to make Personal Health Social and Economic education a statutory part of the national curriculum.

As we said in our evidence to the committee, despite sustained and important falls in both the prevalence and problems that young people face as a result of their drug and alcohol use, young people in England are amongst the mostly likely to have been drunk before the age of 13 years old. 

Addressing these risks in a developmental way is an important component of an effective preventative response and so we are pleased to support the call for PSHE to be a mandated part of the school curriculum.

This year Public Health England report that more than a quarter of all those under 18 who entered drug treatment were identified and referred to specialist services by schools, colleges and pupil referral units; over half were engaged in mainstream education and a further one in five were in alternative education.

PSHE education can help support pupils in developing the values they bring to health decisions, and in developing the resilience that will allow them to bounce back when mistakes are made.

Earlier this year the new psychoactive substances expert panel made a similar recommendation, for PSHE to be given statutory status, DrugScope hopes that the government will now listen to the evidence collected by the Education Select Committee.

Sick and sanctioned

How do we best engage people with drug and alcohol problems but who seem unwilling to enter treatment?  The debate has been re-ignited again this weekend by a proposal by the Conservatives that, should they win the next election, Dame Carol Black will be asked to look at whether those on sickness benefits with drug, alcohol and obesity issues should have those benefits reduced if they refuse treatment.

A recent Freedom of Information request to the DWP indicates that there are about ninety thousand people claiming sickness benefits where drug and alcohol problems are their most significant issue; but it isn't clear how many of those are not engaged in treatment already.

As the Guardian in their coverage of the proposals makes clear, this isn't the first time these sorts of ideas have entered the political debate.  Last year saw similar ideas proposed in relation to those claimants with mental health problems though those have not resurfaced in this proposal.

The Guardian's report points out that DrugScope has been critical of previous moves to introduce benefit sanctions on people with drug and alcohol problems, both under this government and the previous one.

Indeed it has been pointed out to us that this government explicitly ruled out the approach they are now proposing, with Lord Freud telling the House of Lords:

First, it mandates claimants to do something, such as being tested for drugs, that is not directly about helping people to approach the labour market. That does not mean that entering treatment is not the right approach to help many claimants who are substance dependent to address their barriers to work, but-and this leads to my second reason-claimants enter treatment for a series of complex reasons, and whether or not they succeed also depends on a series of complex reasons. Forcing claimants to answer, for example, questions about possible drug use, requiring them to attend substance-related assessments about drug use and insisting that claimants enter a mandatory rehabilitation plan if they decline to enter treatment voluntarily would be asking them to do something a large proportion of them would not want to do. If we took the approach of the previous Government, we would create a high risk of those claimants immediately failing these requirements and having to be sanctioned.

10 Interesting Things about Alcohol and Other Drugs (February 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:

• Deaths amongst opioid users (especially those which are not overdose related); 
• Children in need and care and substance use problems; 
• Multiple and complex needs; 
• Trends in police recorded drug offences; 
• Gang membership, dependency and mental health problems; 
• Seizures of synthetic cannabinoids in prison; 
• Public perceptions of the safety of drug taking 

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).

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.

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.