Headspace: Not sorted for E’s or whizz

While the forensic information has yet to be made public, the tragic death of Nick Bonnie at the Warehouse Project in Manchester (28 September) appears to be the latest in a series of deaths linked either to strong ecstasy or the PMA-ecstasy combination. Up until 2011, PMA had only been implicated in two deaths in the previous 18 years. That figure leapt to 20 in 2012, while the BBC File on Four programme (29 October, listen here) claimed that figure had already been exceeded for 2013.

From a public health perspective, why this is happening now is almost beside the point; the question is ‘what more can be done to warn club goers of the dangers of using ecstasy?’ And then you have to throw into the mix the numerous anecdotal reports of serious outcomes for users of some of the new compounds, especially synthetic cannabinoids. There are no official statistics on the prevalence of use of substances like Black Mamba, Annihilation and Exodus Damnation – and nobody should be helping the more scurrilous end of the media, by unduly ramping up concerns. But even if the names are just a marketing ploy to encourage sales, the percussive effects of these drugs are all too real.

We could do worse than reinvigorate some of the harm reduction initiatives from the 1990s, when rave culture was at its height. Not that this was exactly free from controversy. The first materials on safer dancing appeared in Liverpool in 1992 published by the Merseyside Regional Drug Training Unit (now HIT). After hearing about the rising tide of MDMA-related A&E admissions to local hospitals, they produced the ‘Chill Out’ leaflet, setting out what has now become standard information about not getting overheated, staying hydrated and so on.

The tabloid response was swift and brutal, with one paper going so far as to suggest that parents go round to the unit’s offices and chuck the director Pat O’Hare in the River Mersey.  It didn’t take too long for that information to appear in medical articles, in materials from organisations like DrugScope (then ISDD) and Release and, significantly, in government literature. The government also backed the London Safer Dancing Campaign; ISDD launched the London Study Safely Campaign aimed at students and there were other similar initiatives around the country. The more responsible venues began supplying free water, chill out areas and allowing drugs workers onto the premises to offer advice and support. Did people still die from taking drugs? Sadly they did, but few club goers could have said that they had no idea about the possible ways they could reduce potential risks.

It is true that for a decade now, most drug use, be it problematic or recreational has been in decline. And we don’t know how much of a health problem we really have with the new drugs – except there seems to be a lot of them about. But there is sufficient anecdotal evidence coupled with the jump in MDMA-related deaths to warrant a step change in thinking about information provision – not least because, as well as traditional indoor venues, the last decade has seen an explosion in outdoor festivals where drug-related fatalities and casualties have also occurred.

Unfortunately, proactive information underlining risk reduction is looking pretty scarce right now. The government would point to the FRANK website as a reliable source of information – which it is. But, as reported in this issue, a survey of school students in Nottingham showed that while FRANK has high brand recognition, virtually none of the students would use it a source of information. This will sound quite Luddite, but whatever new technology can deliver, I would argue there is still a significant role for shoving a leaflet in somebody’s hand, putting up posters and providing other tangible objects of social marketing.

DrugScope continues to get regular calls from a whole range of professionals looking for just this – and we can’t help, because there are no funds for free print distribution these days. And due to financial cutbacks, government funds for similar communications activities have also dried up.

It is impossible to say if more readily available information would have saved those who have recently died; but it has to be worth making sure people are properly informed. After all, when Leah Betts died in 1995, one of the most widely publicised drug deaths of all time, few of the current casualties would even have been born.

Harry Shapiro

The state we’re in

Paul Anders, Senior Policy Officer, DrugScope

Everybody is aware of the pressure that the voluntary and public sector have been under for the last few years. Most areas of public spending have been squeezed to a greater or lesser extent, and some sectors have seen provision and capacity substantially affected. While the drug and alcohol treatment sector has not got off scot-free, the presence of the NTA and the somewhat protected funding structure provided for in the Pooled Treatment Budget (PTB) had sheltered the sector to some extent from the pressures elsewhere.

In April 2013, all that changed. Commissioning responsibilities moved to local authorities accompanied by funding previously indicated for drug and alcohol services, which now forms a substantial part of the local public health allocations. What should be noted here is that while the amount of funding nominally allocated to drug and alcohol services hasn’t gone down, there is (currently) no sign of effective protection or ring-fence for the sector and its clients.

Turning to the Public Health Outcomes Framework, which local authorities will be measured against, we can see that relatively few indicators relate directly to the work of the sector – arguably three out of a total of 66 outcome indicators. While well-prepared providers are already working to demonstrate the way their work supports improvement of other key indicators, there is the risk that local authorities under increasing financial pressure may think that a third of the money delivering a twentieth of the outcomes is not a great deal. Public Health England has a role to play in all of this, although it’s not yet entirely clear what that role may comprise of.

In terms of partnerships with the criminal justice sector, another change has taken place. From April 2013, elected Police and Crime Commissioners (and their staff) have replaced Police Authorities. While they, in effect, take control over their budgets in two stages (in April 2013 itself and then 2014), they will be key players – for example through commissioning Drug Interventions Programme (DIP) successors, or through commissioning outreach or – ultimately – whatever sort of provision they feel would work best locally, which could include none at all, at a time when core police budgets are also under pressure.

Clearly, 2013 could turn out to be a crucial year for the sector –a year zero for two hugely important funding and commissioning reforms. However, it was always unlikely to be a ‘big bang’ year – there are contracts with time remaining, and there was a reasonable assumption that at least some of these new structures would take time to familiarise themselves with their new responsibilities and bed themselves in. However, with around 150 local authorities making decisions about spending on public health, and over 40 Police and Crime Commissioners (PCCs) in charge of community safety and crime reduction, understanding the sector has suddenly become more difficult.

The State of the Sector research, conducted for the Recovery Partnership, is an attempt to address that, and will also provide a useful resource for DrugScope in other activities. The research comprised a large online questionnaire, interviews with services in 9 areas that had been identified as particularly interesting, interviews with a number of chief executives and through Freedom of Information Act requests to every PCC in England and Wales. In London, DrugScope, along with the London Drug and Alcohol Policy Forum, contacted every local authority to learn more about their commissioning structures.

The results so far have, to an extent, been in line with expectations – for the reasons above, it always seemed unlikely that there would have been rapid and significant changes by the end of October 2013 but knowing where the sector has come from will help us to identify the direction of travel more accurately. DrugScope and the Recovery Partnership will be publishing a full State of the Sector report later this year, but produced an interim report for its annual conference in November, focussing on key parts only of the responses to the online questionnaire.

These included:

• 36% of services reported a decrease in funding, of which around a third was due to losing services as a result of recommissioning.
•  41% had been through a retendering or recommissioning exercise in the last 12 months, with 64% expecting to in the coming 12 months.
•  44% reported a decrease in front-line staff numbers, and 63% an increase in the use of volunteers.
•  43% said they were not engaged with their Health and Wellbeing Board, including no involvement in any Joint Strategic Needs Assessment Consultation.
• Around 4 in 10 had had involvement with their Police and Crime Commissioner, but only around 1 in 10 was involved via the Police and Crime Plan consultation.
• 9 out of 10 respondents reported that welfare reform had had a negative impact on their clients.
• No respondents were receiving funding from Jobcentre Plus’s Flexible Support Fund.
• Most respondents identified funding and recommissioning as the biggest single challenges facing their own service.
• The most significant gaps in local provision were (in order) access to housing, partnership / support for clients with complex needs, and education, training and employment opportunities.

The responses to the survey and the interviews carried out with service managers and chief executives paint a nuanced picture of a sector that clearly faces challenges, but is innovating and showing resilience. There are several causes for concern, not least in the external environment, but the outlook is far from bleak – for now.

If you would like to discuss the State of the Sector research, please contact Paul Anders – paul.anders@drugscope.org.uk or 020 7234 9799

Who benefits

Who Benefits? is a broad partnership of charities who want to reframe the terms of the debate about social security. Too often, the portrayal of welfare benefits and benefit claimants in the media and elsewhere is misleading – that benefits are generous, easily obtained, and often a lifestyle choice. We know that that just isn’t the case – work with our members and directly with clients shows only too clearly that people are facing increasing hardship due to a range of factors, including the Work Capability Assessment and the on-going process of welfare reform. Coming from a drug and alcohol perspective, we’re also acutely conscious of the impact of stigma; one of the most insidious and harmful effects of the way that the media talks about social security is to increase the stigma felt by all people who have to rely on benefits to get by.

Who Benefits? aims to provide balance to this largely negative narrative by highlighting the vital role that social security and welfare benefits have in supporting people who would otherwise be at risk – the young, the old, the unwell and those experiencing other forms of disadvantage. Who Benefits? believes that no one should go hungry because they lose their job or become homeless because they get ill, and will give a voice to the millions of people who have been helped and supported through at least one point in their lives by social security benefits.

Who Benefits? is coordinated by The Children’s Society, Crisis, Gingerbread, McMillan Cancer Support and Mind, and supported by dozens of other charities and community groups from a range of sectors, including DrugScope. If you’re interested in supporting or joining the campaign, you can find out how here.

Paul Anders
DrugScope Senior Policy Officer

Turning lives around? Drugs, alcohol and the Offender Rehabilitation Bill

As summer comes to an end and politicians return from recess, the Offender Rehabilitation Bill is about to continue its path through Parliament. The Bill – which was published in May, alongside the Government’s response to the ‘Transforming Rehabilitation’ consultation – is comparatively short, but nevertheless important, and contains a number of provisions that are likely to have an impact on those with drug and alcohol problems in contact with the criminal justice system.

Most significantly, perhaps, the Bill introduces a post-custodial licence period for short-term prisoners (those sentenced to up to 12 months), as well as a period of “additional supervision for the purpose of rehabilitation” in the community for anyone sentenced to up to two years’ custody; the licence period and the new supervision period will, together, last 12 months. So, someone sentenced to six months’ custody – who, under the current regime, would be released after three months in prison, with no supervision – will, under the new legislation, serve three months in custody, three months on licence in the community, followed by nine months of supervision.

The Government has set out clear reasons for these provisions: reoffending rates for those released from short prison sentences are high, and post-release supervision will address this through tailored support to help people ‘turn their lives around’. The lack of support for short-term prisoners has been a concern for DrugScope and others for a long time, and the principle of post-release support is an important one. But there are risks, too: it’s possible that the new licence and supervision periods will mean an increased numbers of breaches. This is a real risk for those with drug and/or alcohol problems, who may lead ‘chaotic’ lives, and find complying with the conditions imposed on them difficult. Apart from the cost attached to this (which the updated impact assessment for the Bill puts at somewhere between £6 million and £42 million annually), there’s also the question of the impact of  additional sanctioning as a result of a breach – which could include a return to prison – on ‘recovery capital’ and the pursuit of ‘rehabilitation’. 

There’s an issue, too, around proportionality of sanctioning, and the implications of the new supervision period for this. Someone given a two-week prison sentence, for instance, will in practice be ‘in the system’ for 53 weeks: one week in prison, followed by one week on licence and 51 weeks of supervision in the community.

The Bill also introduces a ‘drug appointment requirement’, which can be imposed as a licence condition, or during the new supervision period. Under this, you would be required to attend appointments with a view to addressing your “dependency on, or propensity to misuse, a controlled drug”. The requirement has to set out who the individual subject to the condition has to meet with (who must have “the necessary qualifications or experience”), where and when the appointments will take place, and the duration of appointments.

Under the Bill’s provisions, there is no “requirement to submit to treatment”. However, there are unanswered questions about what “treatment” means in this context, and how it may be interpreted in practice. It could, for instance, be interpreted to mean only medical treatment, meaning that some individuals might be required, for example, to participate in some forms of psychosocial interventions; further clarification is needed in this area. There are also potential problems as a result of a lack of specialist provision in some areas: this could result in some people being mandated to attend appointments at services that are not able to meet their particular needs effectively, or, in some cases, where their safety could be compromised – for instance, women who are in intimate relationships that are abusive.

Finally, as some DrugScope members have highlighted, the evidence for the effectiveness of mandating people to attend appointments as a way of ensuring engagement with treatment is mixed – for instance,  the required assessment process in the Drug Interventions Programme (DIP). DIP has been very successful in some respects; the National Audit Office (2010) cites Home Office research that crimes committed by those receiving DIP support and in drug treatment fell by 26% compared to their frequency of offending on entering the programme. However, it’s also significant that of those who were assessed under DIP in 2010-11, only 29% went voluntarily from assessment into treatment, with 6% successfully completing this treatment.

It’s positive to see the Government paying attention to those with drug and alcohol problems in the criminal justice system, and improving resettlement support for short-term prisoners. But there are a number of issues with the approach it is taking, which DrugScope has raised with the Ministry of Justice and will continue to pursue.


Gemma Lousely,
Policy Officer

Only connect

I was recently sent a classic cartoon strip from Scott Adam’s Dilbert series, which documents the indignities and inanities of office life. This strip is set at a meeting where an intern has been invited to introduce himself to new colleagues. ‘I am Asok the intern’, he begins, ‘I report to you. But I also report to Alice on a dotted line. And I report to Carol on a fuzzy thin line. I have a blinking irregular line to Wally, and a wavy brown line to Dilbert’, at which point Alice buries her head in her hands and says ‘please make this stop’.

This strip may strike a chord with DrugScope members who are adapting to a wide range of new structures, which relate to each other in a variety of ways. These include Directors of Public Health, Clinical Commissioning Groups, Health and Wellbeing Boards, Healthwatch (both nationally and through its 152 local centres), Public Health England (nationally and through 15 regional centres), NHS England and elected Police and Crime Commissioners.

There is clear potential in so much simultaneous system change for a proliferation of dotted, fuzzy, blinking, irregular and wavy lines – particularly as different initiatives have been developed by different government departments, and may not always have been exhaustively choreographed.

Take, for example, Public Health England (PHE). At national level, strategic leadership for substance misuse sits with the PHE’s Directorate for Health Improvement and Population Health. But there is no direct line from this directorate to the 15 PHE regional centres (and their substance misuse teams), which are overseen by PHE’s Operations Directorate. The ‘line’ from PHE to local public health budget holders is also of the dotted variety. The recent PHE document ‘Our priorities for 2014-15’ explains that ‘PHE will not performance manage local authorities’, with public health ‘led locally by elected members’. (It was reported at a recent meeting attended by DrugScope that PHE Regional Directors may have autonomy to set their own local priorities independently of PHE nationally – raising intriguing questions, if true, about the scope and force of PHE’s national priorities and strategy within the wider organisation.)

To take another example, DrugScope recently met with the drug and alcohol team within the London Mayor’s Office for Policing and Crime (MOPAC). MOPAC is responsible for discharging the Police and Crime Commissioner role in London, and has identified ‘developing smarter solutions to drug and alcohol crime’ as a strategic priority in the London Police and Crime Plan, but it has limited say in the design and development of treatment services for offenders. The MOPAC team is therefore busy forging connections with decision-makers in the 33 London Boroughs – for example, Health and Wellbeing Boards. They are also working with the PHE London regional team, and thinking about how their work might eventually link up with the Ministry of Justice’s Transforming Rehabilitation reforms.

It was in Howard’s End, that the novelist E M Forster wrote ‘Only connect! That was the whole of her sermon. Only connect the prose and the passion, and both will be exalted, and human love will be seen at its height.’ That might somewhat overstate the benefit for us, but certainly ‘connecting’ will be critical for the future of drug and alcohol services. On a positive note the ‘fuzziness’ and ‘waviness’ of some of the lines could be viewed as a welcome indication of ‘flex’ and fluidity and an opportunity for creative inter-agency work. A lot will then depend on pro-active local work to ‘join the dots’ and ‘build recovery in communities’.

On a practical level, creating robust local forums and getting the right people to attend them is critical (think, for example, of the history of Drug Action Teams). It’s also important that busy people are supported to prioritise the activity that is needed to build relationships and effectively link up with others (for example, at a basic level, in job descriptions and work plans). Organisations like DrugScope have an important role to play in catalysing these processes and supporting members to engage effectively. In the autumn, for example, we are hosting a series of regional events on ‘building recovery’ in this new environment on behalf of the Recovery Partnership, and will be in touch as this – and other related work – develops.

DrugScope is currently monitoring, for the Recovery Partnership, developments for drug and alcohol services in light of the significant changes for the sector and related services. Find out more and tell us about any concerns in your local area at http://www.drugscope.org.uk/partnersandprojects/RecoveryWatch

Marcus Roberts
Director of Policy

The Challenge of Change: Improving services for women involved in prostitution and substance use

DrugScope, with AVA (Against Violence and Abuse), has recently published ‘The Challenge of Change: Improving services for women involved in prostitution and substance use’, the report of a research project that encompassed an evidence review, interviews with women with a history of prostitution and substance use, an online survey of services, and observational site visits. Following a launch event at the House of Lords on 2^nd July, hosted by Baroness Corston, a London-specific launch will be taking place at City Hall on 18^th July, with the Deputy Mayor Victoria Borwick speaking at the event.

As its title indicates, the focus of the ‘Challenge of Change’ project has been on policy and practice to address the drug and alcohol treatment needs of women involved in street-based prostitution. While there are no good estimates of the number of women involved in street prostitution and substance use, the Drug Treatment Outcomes Research Study (2007) found that 10% of women starting drug treatment said they had exchanged sex for money, drugs or something else, indicating that the size of this group is significant. As our research highlighted, women involved in prostitution and substance use experience considerable harms, including mental and physical health problems, sexual health risks, and very low self-esteem. Violence was also a significant issue for most of the women interviewed for the research, from a partner or, more often, from a client or ‘punter’.
 
In spite of this, women involved in prostitution and substance use command little attention within national policies; the 2010 Drug Strategy, for instance, contains no mention of the words ‘prostitution’ or ‘sex work’, or even ‘woman’, ‘women’, or ‘girl’. Where drug and alcohol problems among women or involvement in prostitution are mentioned, guidance is rarely provided on addressing the issues together, despite the mutually reinforcing nature of drug use and prostitution. All of the women interviewed for our study reported working on the streets to obtain money for drugs, and many made it clear that this was the reason that they became involved in prostitution in the first place.

The qualitative interviews, which were conducted by peer researchers, highlighted the barriers to accessing services that this group of women can face. These include personal barriers, such as very low self-esteem, as well as organisational barriers, including service hours of opening and a lack of childcare provision. A key issue for these women is the relationship with their keyworker. For such a vulnerable group, consistency is crucial to aid engagement with services; many women feel the effects of ‘double stigma’ as a result of using drugs and being involved in prostitution, and it takes time to develop the trust necessary to open up. However, several interviewees mentioned that they had experienced frequent changes in keyworker. Interviewees also spoke of feeling ‘judged’ or ‘looked down on’ by staff following disclosure of their involvement in prostitution, and disparities in gender and age were also highlighted as problematic.

The research also identified positive interventions for women involved in prostitution and substance use, including evening opening hours for services, outreach provision and support with childcare arrangements. Women-only provision was identified as crucial, and interviewees also spoke of the importance of support from ‘real’ peers – that is, women with experience of using substances and involvement in prostitution. The research highlighted the tailoring of standard drug and alcohol programmes as an effective approach, and the importance of integrated provision, to address the multiple needs of this group of women, was also clear.   

While there are services that are working to address the specific needs of these women, our research highlighted that the problems they face are not always well catered for. Tailoring of standard programmes remains underdeveloped in substance misuse services, and while all the services we surveyed said they provided access to domestic and sexual violence services, only a minority had these available in-house. Peer support was widely available; however, there was less ready access to women-only peer support. Finally, although many women interviewed for the research spoke about wanting longer-term change in their lives – getting a job, having a nice home, being with their children – in-house support with education, employment and housing was not available in the majority of services we surveyed.

Our report sets out good practice recommendations for services, as well as policy recommendations for decision makers and commissioners, which we believe will improve services for this marginalised, stigmatised and traumatised group of women. The challenge now is to ensure that these recommendations are heard and, of course, implemented.

 

‘The Challenge of Change: Improving services for women involved in prostitution and substance use’ is available here.

Gemma Lousely, Policy Officer

Through my in-tray this month

Rather than focussing on one individual area of policy, it might be useful to look in brief at a number of issues that I have been working on. The sector can be affected not only by decisions relating directly to people with histories of drug and/or alcohol use or services that support them, but also those that have a wider application. This month, there are examples of both – the role of Jobcentre Plus in the reformed welfare system, the evolution of the Government’s Social Justice Strategy, and DrugScope’s monitoring of commissioning and funding arrangements for drug and alcohol services.

Jobcentre Plus

In April, the Work and Pensions Select Committee announced an inquiry into the role of Jobcentre Plus in the reformed welfare system. Whilst most people will be aware of the rise of contracted-out provision (through labour market interventions such as the Flexible New Deal and then the Work Programme) and the increased use of the internet for making and managing claims, the role of Jobcentre Plus is still central to the relationship between the Department of Work and Pensions and the individual.

With Universal Credit due to start national roll-out in October 2013, Jobcentre Plus will have a different and increasingly important role – for example, applying ‘tailored conditionality’ for people entering structured drug or alcohol treatment, negotiating a Claimant Commitment that better reflects an individual’s circumstances, and dealing at first instance with claims for what is currently income-based Employment and Support Allowance, but will in future be part of Universal Credit. On the labour market and job brokerage side, Jobcentre Plus will still be responsible for supporting people towards paid employment prior to any referral to contracted-out provision such as the Work Programme.

In a joint response with Homeless Link, DrugScope submitted evidence concerning current claimant experiences of Jobcentre Plus, as well as outlining some concerns about the future. We need frontline Jobcentre Plus staff who have genuine understanding of the particular needs and barriers of people with histories of substance use, and are able to support people to disclose. We need services that are joined-up and work collaboratively with treatment providers, Work Programme providers and others. We need a conditionality regime that recognises the genuine problems some people have in understanding, remembering and carrying out the expectations placed on them, and when people are ready and able to progress into work, we need to see diverse services that can provide skilled, specialist employment support.

You can read the submission here.

Social Justice Strategy

In March 2012, the Government published “Social Justice: transforming lives”, a strategy that sets out a vision of social justice. Whilst many concepts of social justice have focussed on process and comparative disadvantage, the strategy instead looks at particular groups – families, young people, unemployed people, and disadvantaged adults, and attempts both to articulate the problems, and what the Government is doing to tackle them. Much of the language used in the strategy will be familiar to those in the drug and alcohol sector - prevention and early intervention; recovery and independence, locally designed and delivered solutions; payment by results and multi-agency delivery.

In April 2013, the Government published an updated Social Justice Outcomes Framework along with a one-year review of the strategy, stating more explicitly the indicators to be measured. A number of indicators identified and factors referred to will be of interest to treatment providers – for example the indicators directly concerning people successfully completing drug or alcohol treatment, gaining employment and (where relevant) ceasing offending, but also related subjects such as homelessness, financial exclusion and debt, educational outcomes for young people and health inequalities.

The Centre for Economic and Social Inclusion (Inclusion) has been commissioned by DWP to develop a Social Justice Toolkit that will provide an easy-to-use overview of Social Justice Indicators (based around the themes of families, young people, the importance of work, disadvantaged adults, plus delivering social justice) in all local authorities. The aim is to produce an easy to use tool for local policy makers, commissioners and service providers, to aid understanding of local factors and priorities. DrugScope, along with other agencies including Making Every Adult Matter (MEAM) is working with Inclusion to identify potential data sources with the aim of launching the toolkit in July 2013.

Monitoring

April 2013 saw further changes which will continue to transform the commissioning and funding of drug and alcohol services. Two of the most visible aspects of this are the transfer of public health responsibilities to Local Authorities and the election last year of Police and Crime Commissioners who are significant players in commissioning services that cut across substance use, criminal justice and offending.

These major changes are taking place against a background of further reforms that either relate directly to the sector, or could otherwise have some bearing, for example the folding of the NTA into Public Health England, payment by results, changes planned to offender rehabilitation and welfare reform. Across different policy areas, the continued drive to commission joint services and encourage partnership working is plain.

With so much decision making devolved to local level, DrugScope  - with the Recovery Partnership – is actively trying to understand the national picture. We are currently mapping local decision making and commissioning structures – DATs / DAATs, Directors of Public Health, Health and Wellbeing Boards as well as Police and Crime Commissioners and other stakeholders. We’ll be looking at what priorities they are setting, how they are setting them, and what changes to funding and commissioning occur as a result. Later this year, we’re planning on carrying out a state of the sector – or SOS - survey looking directly at the experience of services and service providers.

However much we can do, nothing counts as much as eyes and ears on the ground. On behalf of the Recovery Partnership, DrugScope has established RecoveryWatch, a system enabling people to let us know of local developments – big or small, positive or negative – to help to inform our work over the coming months.

Whatever your role, your information will be welcome and will be treated with the strictest confidence. You can find out more about RecoveryWatch here.

Paul Anders,

Senior Policy Officer