Select Committee on Home Affairs Appendices to the Minutes of Evidence


Memorandum submitted by Turning Point



  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).


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.



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.


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.



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).


  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.


  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.


  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.


  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.


  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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