APPENDIX 12
Memorandum submitted by Turning Point
SECTION 1
INTRODUCTION
Turning Point is a social care charity, founded
in 1964, working with people facing multiple challenges. It is
one of the largest voluntary sector providers of substance misuse
services and a major provider of mental health and learning disability
services. Our current portfolio of over 100 services in England
and Wales, spans rehabilitation, residential care, offender treatment
programmes, structured day programmes, community education and
street level advice and support.
Last year, our services were accessed by over
90,000 people at differing levels, with at least 24,000 having
an active file. In the last financial year April 2000 to March
2001 Turning Point's turnover was £28.3 million.
Turning Point welcomes the opportunity of contributing
to this Inquiry. Our experience is drawn from our work in the
fields of mental health and learning disability as well as substance
misuse. We hope that this "cross sector" perspective
will help to underline the importance of a drugs strategy which
is fully integrated with an alcohol strategy and neighbourhood
renewal work. (This is explored in more detail in Section 3).
KEY RECOMMENDATIONS
Turning Point
— supports the idea that criminal procedures
should no longer be initiated for the possession of small amounts
of any scheduled drug;
— supports a focus on treatment and
access to treatment rather than punishment;
— supports a focus on community health
as well as individual health; and
— believes that the rhetoric around
"a war on drugs" is highly unhelpful and is frequently
interpreted as a war on drug users. Language that realistically
describes specific drugs and their effects would be a far more
constructive way forward.
SECTION 2
IS THE
GOVERNMENT'S
CURRENT DRUG
POLICY WORKING?
2.1 Positive points on the drugs policy
— the Government's 10-year strategy
has driven drugs and many associated issues up the political and
public agenda;
— there has been more investment and
funding available in treatment although much more is needed. To
date, this has been in treatment services within the criminal
justice sector;
— there are some areas where there
has been definite improvement. Widespread adoption of QuADS (Quality
in Alcohol and Drugs Services) has introduced more rigorous protocols
for service delivery—and formalised expectations around
quality of services and development; and
— the introduction of the National
Treatment Agency for England to provide "more treatment,
better treatment and more inclusive treatment". (Paul Hayes,
evidence 30.10) should lead to a greater consistency of services.
Turning Point welcomes the review of the strategy
and the Home Secretary's recent proposals concerning changes in
drug classification, treatment and harm minimisation policies.
2.2 THE
LAW
The effects of decriminalising certain drugs
The law as it currently stands provides the
UK with some of the strictest laws in Europe whilst evidence suggests
that this has had little effect on quality, quantity, price or
supply of drugs.
The example of decriminalising cannabis is a
useful model and the experience should be used in reviewing drug
classification more generally. It would also be helpful if debate
were focused more around patterns of usage, rather than on the
class of a drug.
Turning Point believes that criminal procedures
should no longer be initiated for the possession of small amounts
of any scheduled drug but recommends that there should be a review
of all drug classifications, based on a realistic assessment of
the harm caused, in order to establish a credible and comprehensive
drugs strategy.
The dangers of possession of cannabis being a
criminal office
Turning Point believes that prison is never
an acceptable environment in which to deal with possession.
It does not serve a useful purpose for individuals
or society if recreational users are brought closer to the consolidating
their criminality. A criminal record makes education, employment
and family relationships much more difficult at a crucial stage
of a young person's life and they are likely to learn more about
drugs and more serious crimes inside prison, than outside it.
Currently, cannabis use brings a vast number
of (young) people into contact with the "criminal" world
and people who may be supplying more harmful drugs. The risks
are greater if young people have an unstable family background
and are living in deprived areas with high unemployment and few
opportunities.
Benefits of the possible changes in the drug laws
Changes would be beneficial because:
— a shift away from supply side interventions
to the demand side is thought to pay dividends in terms of reducing
longer term problematic drug use and associated anti-social behaviour;
— the public and political focus should
shift to the drugs that cause the most harm, with the corresponding
investment in time and resources for treatment and preventative
work;
— the current system of classification
lacks credibility as it is not based on the relative harm caused,
or dangerousness of use;
— changes to the drugs laws would also
greatly enhance the credibility of drugs education work. For example,
ecstasy is classed alongside heroin and cocaine, but is not perceived
by some young people as being as dangerous and so when the police
and other workers are talking about other Class A drugs, these
more serious messages are also being discredited;
— reclassifying certain drugs will
not necessarily mean that they will be seen as without risks—tobacco
carries a health warning and alcohol should too;
— decriminalisation of some drugs would
have the added advantage of bringing regulation to production
and supply; and
— currently, a criminal record for
possession of drugs such as cannabis or ecstasy is often a barrier
to treatment, with widely differing interpretations of the law
across the country. This could be overcome by a more credible
and consistent drugs policy.
2.3 HEALTH
IMPLICATIONS OF
DRUG USE
Drug use and mental health
— drug use can mask some serious pre-existing
mental health problems and some drugs, when diagnosed, are intentionally
used for self-medicating purposes—ie to alleviate symptoms
of conditions such as schizophrenia;
— drug misusers share problems related
to other socially excluded groups—low-self-esteem and with
stimulants paranoia, potential episodes of psychotic behaviour;
— at Turning Point, we recognise that
a high proportion of clients face multiple challenges, but it
is only recently that dual diagnosis is being more widely recognised.
(In fact, "dual diagnosis" is a misnomer as it is becoming
equated solely with the interface between substance misuse and
mental health, whereas it should include the interface between
any two needs. The vast majority of Turning Point clients have
a multitude of need thus rendering "dual diagnosis"
meaningless.) The term "complex need" is often more
appropriate;
— the issue is not about providing
"dual diagnosis" workers and services, but about enabling
services to address the complexity of need. The current situation
is that it falls to commissioners who proscribe that services
are either one discipline or the other. Thinking needs to shift
towards continuums to give a meaningful representation of complexity
of needs. Models of service delivery need to allow for a person
presenting different primary needs over time.
Example: At the Junction Project in Brent, a
staff member works with substance misusers who have a high level
of mental health need. He works in conjunction with mental health
teams and either works with clients directly or provides specialist
support to the mental health teams. Mental health service users
are known to experiment with non-prescribed drugs as a form of
self-medication, this is known to include alcohol, cannabis and
crack cocaine as well as other substances.
Drug use and physical health
The physical effects of long-term problematic
drug use are well documented. The majority of Turning Point's
clients are problematic drug/alcohol misusers, who already have
significant health problems, related to prolonged substance misuse—poor
diet, weight loss, less effective immune system, more prone to
infection etc.
Injecting drug users face further risks from
blood-borne infections such as HIV and Hepatitis A/B/C, where
information about, and equipment for, safer injecting is not readily
available.
SECTION 3
CHANGES THAT
TURNING POINT
WOULD LIKE
TO MAKE
TO THE
DRUGS STRATEGY
INCLUDE:
3.1 A change in emphasis from criminal justice
and punishment to treatment
Experience tells us that a drugs strategy would
be more effective if greater emphasis were placed on drugs misuse
as a health and treatment issue rather than a criminal justice
one. This is not a soft option, but the better option.
— it is cheaper than criminal justice—for
every £1 spent on treatment, £3 saved on criminal justice
(National treatment Outcome Research Study);
— emphasis on deterrent has not reduced
drug use or drug trafficking.
Around four million people in Britain use illicit
drugs every year. (DrugScope). Out of 7,266 deaths from overdoses
of illegal drugs across the EU in 1999—close to half (2,857)
were in the UK. Britain has the highest proportion of users of
heroin, amphetamines, ecstasy and cannabis, while cocaine use,
currently more prevalent only in Spain, is fastest growing in
the UK. Source: Annual Report on the State of the Drugs Problem
in the European Union by the European Monitoring Centre for Drugs
and Drug Addiction as reported in the Independent 27 November.
The vast majority of investment so far has been
through Drug Treatment and Testing Orders, Arrest Referral Schemes
and the Prison Drugs Programme. Furthermore, Turning Point engaged
with this process by developing the only drug court pilot in the
UK—see Annex 1.1. (There is now one drug court in Scotland.)
Such programmes are welcome, but they must not be at the expense
of others who also need treatment, but have not committed a crime.
These criminal justice initiatives have put pressure on existing
treatment and prescribing programme. There are many areas of the
country where people still have to wait six to nine months for
help.
We urge an end to what is effectively a two-tier
strategy. The emphasis should be on an integrated strategy to
avoid some of the pressures and to ensure that non-criminal users
are not disadvantaged.
It is right that a key objective of the Government's
strategy is to protect communities from drug-related crime, but
it is not the only one. We would question Bob Ainsworth's comment
recently (19 October Home Office press release) when referring
to Arrest Referral Monitoring Statistical Update report, that
it confirms that the Government is "targeting the right people,
problematic drug users who re-offend".
Turning Point strongly agrees with the Runciman
Report that the criminal justice system should be carefully targeted
and should not distort the use of services. The allocation of
resources and should not be used to replace other routes to help.
The fact that research on arrest referral schemes shows that a
large proportion of those arrested were not in touch with services
is an argument for more services, not for more arrests. (39 Overview).
We also support Runciman Report's recommendation
for a substantial reallocation of resources from enforcement (62
per cent of budget) to treatment (13 per cent). (37 Overview).
Consideration should also be given to referral
mechanisms in Accident and Emergency departments in hospitals,
who see a vast number of people with drug and alcohol misuse problems.
3.2 A strategy which has the capacity to be
more flexible and include a wider range of treatment models, particularly
targeting hard to reach groups
The vast majority of Turning Point's clients
have multiple challenges, requiring a range of services to meet
their varying needs. A significant part of our work is also with
family and friends and others. More effective models mean better
engagement with the client group which means improved health for
individuals and the community.
The crucial issue for any potential or existing
drug user is prevention or early and appropriate intervention.
It is vital to "capture" clients at their point of motivation.
This is important both for those considering using drugs for the
first time and those who make a decision to seek help or treatment.
It is also essential that drug intervention initiatives are linked
to strategies relating to urban renewal, health improvement and
reducing health inequality.
The following paragraphs contain recommendations
on where more investment and a range of different treatment models
are needed, based on Turning Point's work with people using drugs
who are often hard to reach.
Young People
Early intervention, through a range of appropriate
services, to capture clients at their point of motivation is particularly
critical for young people facing addiction and the devastation
to themselves, their families and communities.
Investment in lower-threshold interventions
not perceived specifically as "drug" or alcohol services
is vital. For example, help with numeracy, literacy, IT, education
and retraining, anger management, which is provided by a number
of Turning Point's services helps to reduce or prevent drug use.
Young people aged 15-18 are crucial. They are
"key" opportunities to intervene which should not be
missed.
Example: SHED project in Sheffield working with
young people under 19 who have been sexually exploited, in local
authority care, care leavers, young injectors—and including
the development of a young people's needle exchange, children
of drug using parents and with those in the criminal justice system.
SHED's experience is that intervention is most
successful if undertaken early. Working with an individual who
has become isolated from family, friends or support mechanisms,
who already has a criminal record, or has an infection such as
hepatitis or HIV is never as successful as undertaking preventative
work to stop such problems occurring. It is hoped that SHED will
soon be an all-encompassing service where young people are not
lost in a system of waiting lists and cross-referrals. (See Annex
1.2 for more information).
Greater provision for culturally sensitive services
for black and minority ethnic groups
Turning Point's Hungerford Project in Soho,
(included in the UK Anti-Drugs Co-ordinators Annual Report 2000-01)
provides a range of services, set up to serve different client
groups. A common feature is its partnership working with other
agencies, to help those in community who are particularly difficult
to reach. In addition to its work with homeless people and the
members of the lesbian and gay community, the project has a number
of culturally appropriate services.
Outreach to the Chinese community. Most Chinese
people will not seek help directly due to the stigma attached
to drug use in a very tight-knit community. The Hungerford employs
one worker who is Chinese, working with Chinese people in Soho
and surrounding area. A conference held in June 2001, Drugs
and Mental Health in the Chinese Community included some workshops
in Cantonese and English and two thirds of attendees were Chinese.
Turning Point's research into drug use among
the Bangladeshi community indicates that especially among Bengali
boys, heroin is increasingly used but because it is smoked and
not injected, they are unlikely to access services through a needle
exchange. They are less visible and so problem is underestimated
by local NHS services.
Turning Point's Southall Service piloted a partnership
project with young Asians living in West London. The service worked
to support with family members and increase access to medical
and other support services.
Poly drug use
It is important to see service-users as people
who may require a variety of different services, rather than define
them as needing a particular "medical" treatment. A
significant number of Turning Point services aim to offer services
which cater for polydrug users, as they represent an increasing
number of its client group. This was confirmed by recent research
conducted by the Borough of Westminster which found that 80 per
cent of drug users reported polydrug use, predominantly opiates
and crack cocaine.
However, we realise that different drugs cause
different problems and for the purposes of this evidence, thought
it helpful to provide specific information about crack/crack cocaine
and heroin.
Cocaine/Crack cocaine
Figures from the British Crime Survey 1999 (conducted
in 1998) reveal a "significant" increase in all the
indicators for cocaine use and reported that 480,000 people used
cocaine in the last 12 months. Of those drugs defined by BCS as
"highly addictive" cocaine is the most widely used with
6 per cent of 16-29 year olds saying they have tried it.
Cocaine and heroin are specifically named in
the drugs strategy, particularly to reduce its use among the under
25s.
Turning Point's own information would back trends
of an increase in crack cocaine use, especially in the South.
Although still a relatively small proportion, there has been almost
a fourfold increase in the South over five years. In 1996 only
4.8 per cent reported crack as their primary drug of choice, but
in 2001 this is 12 per cent.
Druglink, a Turning Point service in Hammersmith
and Fulham, has also noted a sharp rise in the number of identified
crack cocaine users using its services. (See table below, based
on total number of clients = 1,000).
| Year | %
|
| 1997-98 | 24
|
| 1998-99 | 31
|
| 1999-00 | 39
|
| 2000-01 | 44
|
Currently there appear to be pockets of crack use such as
London and Manchester. There is not necessarily a need to set
up specialist units everywhere yet, because it is specific to
certain areas, but there is an urgent need to get expertise around
crack into more general facilities—to be aware of its use
and know how to approach it and to plan effectively.
A key issue for the development of services for people with
problematic crack cocaine use is the development of research data
and clear models of working.
Due to the nature of crack cocaine there are limited pharmacological
interventions available. Concentration on more holistic approaches
seems to be the most helpful way forward with cognitive behavioural
models showing encouraging results at this early stage.
Most drugs services are set up for opiate and not stimulant
users, so there is currently no definitive model of success. However,
Turning Point has developed some services specifically for stimulant
users.
For example, the Hungerford Project in Soho has been seeing
crack users since 1988, but in a more structured way over the
last two and a half years. It is important to establish local
partnerships, especially with the local estates and have a staff
team which reflects the local community.
Further information on Druglink, a Turning Point service
based in Hammersmith and Fulham is in the Annex.
Heroin
Pharmacological treatment models are the most common in the
UK, but achieving country wide consistency in methadone prescribing
services should be a priority in the drugs policy.
Prescribing
NHS drug dependency units still have long waiting lists—in
some cases up to six months. Private doctors have sometimes been
used. However, the perception is that a lack of knowledge and
necessary experience often leads to over prescribing and leakage
onto the black market.
There is a shortage of specialised generalists among GPs
and no co-ordinated infrastructure to help find them. As a voluntary
sector provider, it is important that Turning Point works with
GPs to provide a seamless service. However, it is our experience
that it is difficult to find GPs for a shared care service because
training on drug use is not part of any training rotation.
To help tackle this shortage, Turning Point urgently recommends
that prescribing for drug users is made an integral part of all
students' medical training and that drug use is addressed as a
health problem and one which is within the remit of local GPs.
Despite Comprehensive Spending Review money being made available
for GPs to reduce drug related deaths, 94 per cent of doctors
are still unwilling to prescribe to patients, often will not see
them and so do not pick up warning signs and signals. (Source:
Society Guardian: Bitter Pill of prescribing heroin 9 November
2001, Dr Brian Iddon, Chairman of the All-Party Misuse of Drugs
Group: These doctors (who prescribe heroin substitute drugs) fall
into a group of people who believe drug addicts are victims and
need specially tailored treatment and counselling, rather than
criminals who should be punished. They are something of a rare
breed, since the majority of GPs, some 94 per cent are unwilling
to treat drug users. This leaves addicts with no alternative other
than to continue to use street drugs.)
Turning Point supports the target to increase problem drug
misusers in drug treatment programmes, but the targets are very
ambitious (55 per cent by 2004, 66 per cent by 2005 and 100 per
cent by 2008) given the problems highlighted above.
There needs to be a change of culture among GPs so that those
who do work with drug users are not ostracised.
3.3 Harm Minimisation
In some instances, harm minimisation targets are a more realistic
goal than complete abstinence. Turning Point recommends that a
revised drugs strategy should give more focus and investment to
harm reduction. Following are some suggested models based on Turning
Point's experience.
Mobile needle exchanges
The mobile needle exchange service operated by Turning Point's
Hungerford Project in Soho is a relatively new, but very busy
service. In its first 11 months (from December 2000 to October
2001), it has seen 37,121 contacts—an average of 150 people
a day, and 1,913 different individuals. It aims to adopt a joined-up
approach to community safety and encourages long-term chaotic
users to access primary health care services. It also distributes
Vitamin C and citric acid.
There is also a mobile needle exchange being piloted in Wakefield.
There is a need for a greater spread of needle exchanges, catering
not just for the larger populations.
Locality Prescribing
This model has been very successfully developed by Turning
Point in the Wakefield area. Local GPs conduct clinics for methadone
users, run according to Department of Health guidelines, at Turning
Point's existing substance misuse projects in Wakefield, Castleford
and Hemsworth. Such is their success that there are five clinics
with a further one to run soon, seeing an average of 60 people
per clinic (and a total of about 180 individuals). This set up
is popular with clients because:
— the clinic is in a familiar setting which is less
intimidating than a doctor's surgery;
— they are accepted and their situation/needs are
known by the drug workers;
— they are treated with dignity and respect.
Importantly, these factors encourage regular attendance.
It is popular with GPs because:
— clients who potentially disrupt a surgery are
seen in a more appropriate separate setting;
— the "through-put of clients" is arranged
by the voluntary sector organisation;
— clinical notes and other background information
is provided by a Turning Point drug worker. They appreciate being
able to draw on the support and knowledge of drugs workers.
Nurse-prescribing
There are far more nurses working in the field of substance
misuse than doctors and we suggest possible models of nurse-led
prescribing should be further researched.
Other issues re harm-minimisation
— the Hepatitis B immunisation programme through
the Department of Health is needed, but Hepatitis C is the hidden
killer. Need to engage people in a complete service taking in
pre-test counselling, blood-test and post-test counselling;
— re: reducing drug-related deaths, health authorities
are concentrating on the most chaotic users, but there has been
a rise in the number of people who have been taking drugs for
10-12 years. They are known to local services who often presume
that users know what they are doing, but some don't.
3.4 Better co-ordination of services
There are serious delays in accessing treatment, especially
in residential care which is funded by Local Authorities and Social
Services—first they have to agree need, carry out an assessment,
then sort out financial arrangements and then see whether a place
is available. Both for those with chronic (longstanding) use and
acute (crisis), during a long wait are likely to continue their
habit and lose interest in treatment.
There are also long waiting lists for prescribing programmes.
There should be a review and better targeting to speed up
eligibility, assessment and placement. Inconsistencies in levels
of funding and criteria make this worse and poor budgetary management
of some authorities, make it difficult to access treatment at
certain times of the year.
3.5 A more joined up approach to resettlement support
Following re-settlement after treatment or a prison sentence,
responsibility for drugs services often fall between the relevant
agencies. Lack of support during this crucial transition stage
and the non-specialist support of what is available, means that
vital links are not made. Problems with the take up of referrals,
missed appointments and resettlement into the community reduce
the gains made during a "successful" treatment programme.
The North Tyneside Resettlement Project is one example of
a project which seeks to address the gap in service provision
to offer seamless approach to resettlement support. It acts as
a bridge in the transition from custody or rehabilitation to community
resettlement. (for more information on the North Tyneside Resettlement
Project, see Annex 1.4.)
3.6 Improved statistical information
Targets should be realistically reviewed against a backdrop
of improved statistical information.
Better co-ordination of existing data
Agencies are being asked to report back in a plethora of
different ways. There should be better co-ordination of information
that is already available locally and nationally from the police,
DATs and details required by commissioners. Accurate information
would increase the effectiveness of prevention/early intervention
programmes, regeneration and community health initiatives.
Recommendation: The National Treatment Agency should define
universally recognised criteria and systems. It should require
commissioners to use the same model, at least for a set period,
while research is undertaken to enable comparisons to be made.
Early warning systems
The Runciman Report found no evidence for early warning systems
in the UK as there are in the Netherlands, Holland and US (Drug
Abuse Warning Network) and twice yearly Pulse Check, (based on
information from a variety of people working in the drugs field).
Recommendation: It should be a priority to establish a reliable
and fast-working system to identify new drugs that may be causing
problems and need to be brought under control, especially as new
designer drugs can be produced so quickly.
SECTION 4
The effectiveness of any Drugs Policy will be increased if
it is closely integrated with similar policies to tackle (1) alcohol
abuse and (2) neighbourhood renewal.
These two areas have an important bearing on the effectiveness
of all four key aims of the UK drugs strategy: to help young people,
protect our communities, to enable people with drug problems to
live healthy lives and to stifle availability of illegal drugs.
In its definition of problematic drug use, the World Health
Organisation recognises the complexity involved—referring
to drug use which causes harm in relation to psychological well-being,
health, the law and social function.
4.1 Alcohol
There is an urgent need for a coherent and robust alcohol
strategy, as shown by Alcohol Concern's report November 2001.
Alcohol Concern: the State of the Nation
Just over £1 million is spent on alcohol prevention
and treatment—compared to £91.45 million on drugs.
One person in 13 is dependent on alcohol in Britain—twice
as many as are addicted to all forms of drugs including prescription
drugs one in 26.
5,508 people died due to alcohol abuse in 1999, a 30 per
cent rise in five years.
The vast majority have multiple challenges, requiring a range
of services to meet their varying needs. Many of Turning Point's
clients using our alcohol misuse services also have problems with
drugs and vice versa.
Recommendation: That an Alcohol Strategy becomes the responsibility
of the National Treatment Agency, with the relevant resources
allocated.
4.2 Neighbourhood Renewal
Drugs and social deprivation
Tackling substance misuse and neighbourhood decline must
be seen as integrated policy objectives, as one has a direct bearing
on the other. For example, the use of crack cocaine most often
takes hold in deprived areas and has a devastating effect on local
communities:
— the Advisory Council on the Misuse of Drugs: Drugs
Misuse and the Environment, Stationery Office 1998 states that
"deprivation is today in Britain likely often to make a significant
casual contribution to the cause, complication and intractability
of damaging kinds of drug misuse. We want in the future to see
deprivation given its full and proper place in all considerations
of drug prevention policy (para 74, p 37);
— the Neighbourhood Renewal Fund is target specifically
at improving public service performance in England's most deprived
neighbourhoods. NRF allocations have been made to the 88 most
deprived local authority districts (determined on the basis of
Indices of Deprivation 2000). Turning Point currently works in
at least 35 of these areas and recognises that people's every
day living environment must be addressed; and
— although there are various funding streams through
Communities Against Drugs (CAD) and Neighbourhood Renewal Fund
and others, little mention is made of drugs services specifically.
Recommendations: a clear drugs focus in neighbourhood renewal
strategies and a review of the multiplicity of funding streams
to make them more straightforward and accessible.
For more information on Neighbourhood Renewal see Annex 2.2.
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