Examination of Witnesses (Questions 240
- 259)
TUESDAY 27 OCTOBER 2009
MR PAUL
HAYES, MR
JOHN JOLLY
AND DR
NEIL BRENER
Q240 Mr Winnick: The information
we have from the Home Office is that during the survey undertaken
in 1996 of 16 to 59 year olds using cocaine it was 0.6%—that
was 13 years ago. The latest information is self-reported drug
use of cocaine rose to 2.3% in 2007-08. It is not a very optimistic
scenario, is it?
Mr Hayes: I can only speak about
the treatment aspect of it. As we have already established the
majority of people who use crack cocaine will probably need treatment.
A very significant proportion of the people who use crack cocaine
are already in the treatment system and the proportion of people
who use powder cocaine who need treatment is very small. I am
not an expert on what actually drives demand for cocaine use but
it is seen as a recreational drug. Over that same period we have
seen a very significant increase in the amount of alcohol that
is consumed, we are much more prosperous society than we were
in 1996, people spend much more time enjoying themselves. As a
drug that is seen as part of the pub-going, club lifestyle, it
is not surprising that we have seen an increase in its use.
Mr Winnick: That is a very interesting
answer.
Q241 Mrs Dean: Has the incidence
of use of crack cocaine increased in the same way that powder
cocaine has increased?
Mr Hayes: Not at all. Crack cocaine
is stable at the moment, it has been stable for a number of years
as has heroin. It is important when we are focusing on the significant
increase in numbers of young adults accessing treatment for powder
cocaine, that actually the numbers of the same age group accessing
treatment for heroin and crack cocaine is very significantly down
and down to a far greater extent than those accessing treatment
for powder cocaine are up.[1]
What we are optimistic that we are beginning to see is the beginning
of the end of the heroin epidemic that began in the 1980s. It
is also important to remember that there is a significant difference
between the two populations. The powder cocaine population are,
if you like, more normal than the crack cocaine population. There
are five times as many powder cocaine users as there are crack
cocaine users but there are five times as many crack cocaine users
in treatment as there are powder cocaine users. That is not because
crack cocaine is 25 times more dangerous than powder cocaine—it
is more potent but it is not 25 times more dangerous—it
is that the people who are using it are different people. The
people who are using crack cocaine like the people who use heroin
are the people who are at the most vulnerable end of our society.
The people who use powder cocaine, some of them are at the most
vulnerable end of society, but there are also the City traders,
the pop stars, the normal metropolitan professionals. When they
begin to experience problems they can actually sort out their
problems, they have enough personal social capital—they
can draw on family support, they can draw on the safety net of
a good income to actually get themselves out of the mess whereas
the people towards the bottom end of society are more likely to
spiral into decline.
Q242 Mr Streeter: Thank you, Mr Hayes,
very much indeed. Before we turn to Mr Brake I would like to ask
you, Mr Jolly, if I may, how much does the Blenheim programme
spend on drug treatments overall each year and how much on cocaine
in particular?
Mr Jolly: Overall the organisation
of Blenheim CDP spends £7 million of taxpayers' money on
treating addictions. Of that £2.5 million is spent specifically
on cocaine and specifically crack projects across London.
Q243 Tom Brake: Dr Brener, can you
tell us roughly how many people would come to The Priory each
year for cocaine addiction treatments and what the average cost
would be?
Dr Brener: It is very difficult
to tease out how many patients of ours come just for cocaine problems;
very few of my patients come for purely cocaine, most of them
have other problems as well, particularly alcohol and cannabis
abuse with that, so it is very difficult to say. We see over 1000
patients a year between the 16 Priories across the country. The
average cost of a residential in-patient treatment programme which
normally is for 28 days is between £15,000 and £17,000.
Q244 Tom Brake: Is it possible to
tell us roughly how much of that is privately funded by individuals,
their companies or insurance and how much is funded by the NHS?
Dr Brener: A very small number
is funded by the NHS; I would think it is possibly less than 5%
is NHS. The vast majority comes from insurance companies, I would
say, something about two-thirds, and about a third is self-funded.
In that programme is included a year's free aftercare of the treatment
programme as well, as well as a family treatment programme, so
it is not just related to the individual.
Q245 Tom Brake: What is included
in the year's free aftercare?
Dr Brener: The free aftercare
is a group therapy programme once a week and follow-up.
Q246 Tom Brake: Is that something
that people in effect sign up to doing or is it something that
is optional if they feel they need to go back and get support?
Dr Brener: Our programme is the
12-step-based programme—it is not exclusively that—and
therefore they will be expected if they wish to continue treatment
to be totally abstinent. We are an abstinence-based programme,
therefore a patient would be expected to sign up for that as part
of their treatment package when they leave.
Q247 Mr Clappison: Very briefly,
without identifying individual organisations, so that we can see
where the problem lies, can you give us a description of the background
and the section of society that people come from who pass through
The Priory?
Dr Brener: To a lot of people's
surprise The Priory unfortunately has a reputation for being a
celebrity waterhole but that is far from true, that is a very
tiny percentage of people who come to The Priory. We get a lot
of people from very different backgrounds—people who might
work as high-fliers in the City through to people in the City
who might be in the post room; they all have the same medical
insurance if they require treatment, so we do get quite a diverse
group of people coming through The Priory. Most of them do have,
unlike some other areas, family support but by no means exclusively.
Q248 Mr Clappison: Would you be able
to say from your experience that there are some professions which
are higher risk from what you have seen in terms of cocaine use?
Dr Brener: In terms in terms of
cocaine use and in terms of powder cocaine certainly people working
in the financial industry are more likely to run into problems.
They have a very high pressured job and they often start using
it, not so much as a reward system but as a system to try and
keep themselves going in highly pressured situations. That certainly
is one of the professions from which we see a number of people,
but there is quite a wide range within that.
Q249 Gwyn Prosser: Mr Jolly, can
you tell us how individuals are referred into your treatment centres?
Mr Jolly: Broadly people come
from a wide range of sources. A proportion basically refer themselves
in for treatment, we get a high number of referrals in from the
criminal justice services, the Probation Service, social service
departments and from housing and homelessness organisations, so
a wide range of access points from people choosing for themselves
to basically come in to people who are quasi-compulsorily forced
to attend our services. It is a broad range and we seek to go
out actually and spread that net as widely as we can.
Q250 Gwyn Prosser: Does the demand
always outrun the supply?
Mr Jolly: No. One of the things
that has worked very well in the treatment system over the last
ten years in this country is that we have been able to expand
our level of provision to actually meet a lot of the supply needs
in relation to substance misuse, so pretty much, for example,
people can access our services as and when they need to do that
without waiting lists, without waiting to actually access services.
Q251 Gwyn Prosser: Dr Brener, can
I ask you the same question in terms of referrals?
Dr Brener: Most patients come
through to us from two sources, either their general practitioner
or occupational health or self-referrals, they are the main sources
of our referral base.
Q252 Gwyn Prosser: If the referral
came through via the GP would the GP do that in the knowledge
that that client had health insurance or private funds?
Dr Brener: Often that is the case.
Quite often the GP refers patients not knowing they have a substance
abuse problem and that is only really discovered when we assess
them.
Q253 Gwyn Prosser: What are both
your views of evidence that we have received that treatment is
very often not available until crisis arrives in a particular
case and that there are long waiting lists?
Mr Jolly: For community services
people can pretty much access services when they are needed, certainly
in terms of open access service provision. The issue is that people
often only choose to actually tackle their addictive behaviours
at the point of crisis. The services are out there, certainly
in relation to community-based services; if we were looking at
residential treatment facilities I would say that our experience
is that access to residential treatment provision has actually
been getting more and more difficult, certainly over the last
four or five years, in terms that it is being gate-kept so that
access to those residential treatment facilities is actually becoming
more difficult rather than easier.
Dr Brener: I would certainly agree
with that. There is what I would call a tipping point in a person's
use of a drug which is often a time that allows them to focus
and understand that they are in crisis. That can often be a very
good way of helping them to recognise the problem and understand
that they cannot live in denial and have to actually make some
changes in their life.
Q254 Tom Brake: Dr Brener, I just
want to come back on something you said. You said that doctors
are referring their patients but not knowing that they are addicted.
Dr Brener: Yes.
Q255 Tom Brake: So why are they referring
them to you?
Dr Brener: A vast majority of
the patients that I see have dual diagnoses of some form. Many
patients come to see me with depression or anxiety disorders,
sometimes with psychotic illnesses, and when you take a history
it becomes much more apparent that associated with that—not
always of course—is an addiction process.
Q256 Mrs Cryer: Dr Brener, The Priory
is for residential treatment.
Dr Brener: Yes.
Q257 Mrs Cryer: People going into
residential treatment and not going home each night, is it effective
because you are separating them from their peer group and peer
pressures or is it the actual treatment that you give them?
Dr Brener: The answer is both.
All patients when they come to treatment in our experience are
quite chaotic, their lives are falling apart in many cases and
they need some structure and some boundaries put in their lives
and residential can be very helpful for that. Separating them
from their environment for a period of time can be quite useful
as long as it is not something that is going to be prolonged where
they become institutionalised; that is why we try to limit the
in-patient treatment to 28 days. During the first week they are
allowed no visitors, no telephone calls in or out, they are not
allowed television sets, any computers or anything of that nature
to focus on the treatment, to get their head into the treatment
programme, which is intense. My patients start work in the group
therapy programme at nine o'clock in the morning and finish about
nine o'clock at night. Isolation is something we really try to
discourage.
Q258 Mr Streeter: Mr Jolly, do you
want to comment on that?
Mr Jolly: We treat people much
more in the community settings in which they live but the difficulties
there are that you have to actually treat people in the context
of what is happening for them, so people are often living a hand
to mouth existemce, basically living on people's sofas, often
in houses with multiple occupancy with many other people around
them who are also misusing drugs. That context is actually difficult,
you have to address those issues as well as actually dealing with
addiction issues, so it can be helpful to move people out of that
environment into residential or more stable accommodation, and
it is one of the things that we work with people to do. The difficulty
with moving people out of their environment and actually treating
them in isolation from their environment is that you have to put
them back into the world. It is one of the dilemmas of the addiction
field in terms of whether you take people out of their environment
and put them somewhere where it is nice and safe and cosy or you
can control the environment and access to drugs to a certain extent,
and then when you have done that you put them back into the same
environment they were before, sleeping on the same couch, or whether
you actually work with people in the environment where they are,
helping them to get the social capital they need in relation to
safe housing, friends, associates and people around them who are
not using. A job, a life and a family back is as important as
dealing with the addiction.
Q259 Mr Clappison: Mr Hayes, we took
evidence last week that the number of referrals from the criminal
justice system for treatment is in effect crowding out people
who are not offenders, but you however deny this. Can you give
us some idea of the proportion of people who are referred from
the criminal justice system and the people who come for treatment
from outside the criminal justice system and the proportion of
resources devoted to each one?
Mr Hayes: About 25% are routed
through the criminal justice system and 75% are either self-referred,
referred through their GP or via some other route. The amount
that is spent is identical; the amount that is spent is determined
by the individual's need. There is no evidence at all that the
involvement of the criminal justice system has actually held back
access to treatment for other people; as John has said, access
has never been more open than it is at the moment. In fact, what
we have been able to do by actually identifying the spend across
government is build a treatment system that is able to not only
meet the needs of the criminal justice system but is also better
able to meet the needs of the remainder of the population.
1 The witness later clarified that, the recent published
figures are for 18-24 year-olds: comparable figures for young
people (under-18) are not yet available. Back
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