Examination of Witnesses (Questions 260
- 279)
TUESDAY 27 OCTOBER 2009
MR PAUL
HAYES, MR
JOHN JOLLY
AND DR
NEIL BRENER
Q260 Mrs Dean: Mr Jolly, are individuals
who are referred through the criminal justice system more reluctant
participants and therefore harder to treat?
Mr Jolly: Yes and no is the answer;
it depends on the context. In this country we have an arrest referral
system so we test people coming through police cells who have
been arrested. At that point you are hoovering up people who are
recreational users of drugs as well as those people with significant
drugs problems, so those people who tend to have a recreational
pattern are actually not at a stage where they define themselves
as having a drug problem and thus are much more reluctant to actually
enter treatment or engage with you, partly because they either
have not recognised that they have a problem or indeed do not
have a problem with their use that is causing social difficulty.
For those people who have significant difficulties who come through
serious offending patterns, once they actually get into treatment
the outcomes are the same. In fact there have been a number of
studies which have been asking precisely that question and focused
on coming out with the answer, I have to say, that it is dreadful
forcing people into treatments, and have been surprised by their
own answers in the research which tell them that there is really
no difference between the two groups.
Q261 Gwyn Prosser: Mr Hayes, in our
evidence session last week we had Mitch Winehouse in front of
us talking about heroin addiction. He suggested that people could
wait up to 12 months before getting treatment even though their
needs were very great. Do you recognise that figure?
Mr Hayes: No, not at all. That
would have been the situation in 2000-01. The Audit Commission
did a study into drug treatment in 2001, reported in 2002, and
they talked about a treatment system that was characterised by
very lengthy waits, and in many ways for the National Treatment
Agency that was one of the key issues we were set up to address.
The situation now is that you can access treatment nearly everywhere
in England—different situations pertain in Wales, Scotland
and Northern Ireland—and 93% of people access treatment
within the target, which is three weeks, and the average time
to access treatment from walking in off the street is now five
working days.
Q262 Gwyn Prosser: I asked the question
because he actually gave the example that in his family dealings
he could afford to use the Priory units whereas other people,
especially at the crack cocaine end and people using heroin, just
did not have that facility, but the three of you have given very
different pictures today.
Mr Hayes: What happens is that
it takes a long time for the popular consciousness to catch up
with what is actually happening on the ground. For a very long
time it was very difficult to access treatment in this country
so it has become engrained in people's consciousness that there
are lengthy waiting times for treatment and it is difficult to
get in. All the evidence is to the contrary. There are 149 treatment
systems with over 200,000 people in treatment, so there will be
the odd horror story, but I am absolutely confident that the figures
provided to us are absolutely accurate. Nearly everywhere in the
country you can now walk in off the street and get treatment,
and the thing that gives me confidence about that is that we have
a network of service users involved n every single local partnership
and they help to shape and commission treatment services and they
sit alongside us when we hold treatment services to account. They
are very quick to tell us if the information that is being put
back to us about waiting times is wrong. They know it because
they are their peers are living it.
Q263 Gwyn Prosser: Just briefly,
Dr Brener, is it right that the Priory are closing down some of
their units across the country, or are you expanding or are you
stable?
Dr Brener: We are absolutely not
closing units, we are quite stable. I do not think we are planning
to expand any units although we are certainly looking at expanding
types of services available and that is absolutely the case. We
have no intention of reducing units.
Q264 Tom Brake: Mr Hayes, could you
just clarify, you said 93% of people were accessing treatment
within three weeks but then you referred to five das; what was
the five days?
Mr Hayes: The average. The average
wait is five working days; the target is three weeks and 93% of
people are at target. If I can pick up on something that was said
earlier about rehab, rehab is a little bit different in that most
people will access rehab once they are inside the treatment system.
Waits for rehab can be longer and they can also sometimes be misunderstood
by the individual. There is a difference between when the individual
will first believe that they might benefit from access to rehab
and when it has actually been agreed with them and the clinician
who is actually in charge of their case that that is the right
thing for them to do, to go to a rehab unit. People's experience
of waiting for rehab once they are inside the system—they
might experience that as being longer than the people who are
actually responsible for their care will experience it as being
and that gives rise to some confusion.
Q265 Tom Brake: Mr Jolly and Dr Brener,
you were nodding as Mr Hayes was speaking there in terms of how
quickly people can now access treatment but could you tell us
what the average waiting time for a referral through to starting
treatment is with your respective organisations?
Mr Jolly: For us—and we
provide many of these community-based services, funded by the
NHS, that Paul has been talking about—the average waiting
time is between two and a half and five days.
Dr Brener: For us the average
waiting time is dependent on assessments so I would think a day
to a day and a half, something in that region.
Q266 Tom Brake: Thank you. Given
the speed within which this is happening, presumably if there
is a critical window within which someone needs to be able to
access treatment, that is being satisfied, is it, given how quickly
you are able to get people on board in your respective organisations?
Mr Jolly: Broadly it is in terms
of doing that, but I would come back to the residential treatment
issue. There is a need and certainly if there is someone whom
we deem needs residential treatment we find it difficult to access
that residential treatment within what we would define as an organisation
as the relevant time window.
Q267 Tom Brake: Would it be the primary
care trust which is responsible for funding that treatment? Where
is the blockage? Presumably they are saying it is too expensive,
is that what is happening?
Mr Jolly: It is an issue around
eligibility criteria and just defining, basically, at what point
residential treatment is a suitable intervention. There are different
approaches that are taken in that respect.
Mr Hayes: To clarify that, part
of the difficulty is that although the majority of treatment is
paid for from collective funds, brought together under the control
of the local drug action team—most of which will come from
primary care trusts—community care funding actually pays
for most residential rehabilitation so it is necessary in most
places to access the local authority structures separately from
the NHS structures. That sets up another layer of bureaucracy,
takes up some time and is not actually as neat a fit as it should
be with the rest of the treatment system. We have been working
with colleagues in local government and in health to try to overcome
that for some time. In many places the procedures have been streamlined
and they work well but in too many places at the moment there
are unnecessary bureaucratic hiccups.
Q268 Tom Brake: Mr Jolly, can I just
ask you whether you are able to cost the impact of this, both
in terms of the health of the users you are talking about but
also in financial terms, in other words treating people in the
community when you are saying actually they should be treated
residentially. What are the health and financial costs of not
pursuing what you believe is the appropriate course of remedy?
Mr Jolly: It is difficult to quantify
across the board but for some individuals the consequences can
be devastating—certainly we have had people who have been
in severe crisis, dual diagnoses, really in need of support who
have committed suicide while waiting for treatment, so there is
an extreme end to this. For some people who do not access the
treatment that we deem necessary we can and do successfully manage
their addiction within the community. It is a continuum in that
sense and not a straightforward question to answer.
Q269 Mrs Cryer: Further to Mr Brake's
question about costs, Dr Brener, would you be able to suggest
to us how much more or less it would cost to put someone into
prison as opposed to putting them into The Priory, and then if
you could both tell me what treatments are available, first at
the community-based Blenheim and the residential Priory?
Dr Brener: I do not know what
the cost of keeping someone is prison is, it is not something
that I am experienced at, but I would think that the cost of keeping
someone in prison is large. There are, I believe, some extremely
good treatment programmes in prison, not always in fact universally
available, but I have had some very good experiences of dealing
with them. I do not think I can really answer that for you. One
of the blocks that we have in the treatment is finding appropriate
accommodation for people once they leave treatment. That might
sound odd when they are self-funding or something of that nature,
but often patients who have been through a 28-day treatment programme
need on-going treatment. Sometimes that is suitable to do as day
care, other times it is suitable to do out-patient work, but some
people need a more protected environment, something we call a
halfway house, which is literally what it says, halfway between
being an in-patient and an out-patient. So they have residential
accommodation with maybe therapy in the mornings and other things
like education or work placements afterwards. In my experience
there is a lack of provision of those for people to move to, to
give them supported care and therefore allowing them the best
opportunity to maintain their recovery.
Q270 Mrs Cryer: You think it is as
important to be focusing on housing and the social needs as it
is on the actual physical treatment.
Dr Brener: It is all part of the
same thing, it runs parallel. I do not think you can separate
it out and say now we are going to only treat your addiction,
we have to treat them within their community—for example
their family structure, often sometimes even their workplace structure.
It has got to be part of the whole thing.
Q271 Mrs Cryer: Is that the case
for the Blenheim?
Mr Jolly: Absolutely, I agree.
First of all we make a very careful assessment of anybody coming
in in terms of their actual needs, and it is not just about their
addiction, it is about their social functioning, their criminality,
other things going on in their lives that impact on them and housing.
We respond by basically delivering many of the treatment measures
we have actually talked about in terms of day care provision,
in terms of set packages of psycho-social interventions, looking
at rehab, relapse, cognitive behavioural therapy, but as important
as all of that is actually seeing people as individuals and responding
to their immediate needs around housing, accommodation, legal
issues, debts and also looking at employment, training and education.
We spend a considerable amount of our time with everybody that
we work with looking at how we can tackle employment, training
and education needs, and that is as important as, basically, the
work we do with addiction because addiction does not stop. If
you do not deal with the issues that led to addiction in the first
place people are going to be back where they were in a very short
period of time.
Dr Brener: I would totally agree
with that and one other thing I would add is that you also have
to deal with underlying psychological problems which is where
a lot of the addiction processes start from.
Q272 Mrs Dean: Could I ask both Mr
Jolly and Dr Brener what the success rates are of different treatments.
Are non-residential services as effective as residential services,
Mr Jolly?
Mr Jolly: That is a difficult
question to answer because we do not actually have that information
and that comparison. Certainly community-based treatments can
be very, very successful but it depends on how you judge success.
Well over 80% to 90% of people are maintained in effective treatment
so we are very effective at actually getting people into treatment
and keeping them in our treatment centres. In terms of actually
getting people through the treatment system and out the other
end, again for our own organisation it is between 61% at the worst
end of our performance up to 93% in terms of people successfully
being discharged from our programmes having gone through. It really
depends on what question you ask; in terms of people being totally
abstinent at the end of that in terms of not using any drugs at
all, about a third to a half of people exiting our treatment will
be using no drugs at all. The answer to the question depends really
on how you judge success.
Q273 Mrs Dean: Your treatments are
not all abstinence-based.
Mr Jolly: They are not all abstinence-based,
no, although our ultimate goal is for people to be abstinent.
We can and do treat people at all stages of their addiction.
Q274 Mrs Dean: Whereas, Dr Brener,
yours are abstinence-based.
Dr Brener: Ours is an abstinence-based
programme. About 98% of people who come through the programme
complete the programme. At one year 25% of the people who have
been through our programme have never used any drugs again, another
50% have relapsed and then gone clean and are at one year clean,
and 25% of our group relapse and continue to use and a percentage
of those die. We are not quite certain exactly what percentage
we lose but we think between 3% and 5%.
Q275 Mrs Dean: Mr Jolly, Sarah Graham,
an ex-cocaine addict told the Committee last week that she needed
eight months residential care in The Priory to beat her addiction.
Is this the level of treatment addicts require? Can non-residential
community-based drug services ever be effective?
Mr Jolly: They can. I cannot comment
on whether that for her was necessary but that level of provision
for some people is required. We do have effective interventions
that work very well for other people that are community-based
and we see regularly people passing through our treatment centres
and using our services who basically do not require that level
of intervention and we can successfully manage them within the
community. Certainly, on-going support over a lengthy period of
time is actually crucial in terms of enabling people to actually
tackle crack addiction.
Q276 Mr Streeter: Mr Hayes, do you
want to add to that?
Mr Hayes: The key thing is, is
it the right intervention for the right person, and it is often
inappropriate to think of these things as being alternatives.
What we want in each area is an integrated treatment system which
is able to respond with the right intervention for the right people.
Our view is that 90% of people will actually do better if dealt
with in the community. If you look back at outcome measures over
the last three years we actually can discern no difference in
long term outcomes for people who have been through community
treatment and people who have been through residential treatment.
What we do know is that both kinds of treatment will work for
the right people, but what we should not do is assume that what
one person's experience was is able to be generalised to the rest
of the population.
Q277 Tom Brake: Mr Jolly, I just
wanted to come back on something you said. I think you said that
between a third and a half of people leaving your treatments were
drugs-free.
Mr Jolly: Yes.
Q278 Tom Brake: Does that mean the
treatment has failed or is it that you have brought people to
a point that you think is a stable one from which they then go
on to do something else in terms of follow-up treatment?
Mr Jolly: That is right; they
would leave us and they may well be referred into other treatment
organisations to take on the responsibility for treatment so of
those who are continuing to use a proportion will be using occasionally
some drugs but basically not in an addictive way, or they will
not be using heroin or crack cocaine but will be continuing to
use other substances on an occasional basis. Many others will
be transferred into other parts of the treatment system who are
actually taking on their care because they are more appropriate
for their level of need at that particular point, so they will
be maintained successfully within treatment. We have been working
with them to actually get significant gains in their social functioning
and to address their addiction, and we are passing them on to
another organisation that will continue that work.
Q279 Tom Brake: Is that transition
always a smooth one?
Mr Jolly: Increasingly it is smooth.
The treatment systems in the UK—certainly in England—have
been focusing very heavily on making that transition smooth and
seamless. It is not always as smooth and seamless as we would
like, but we have made substantial improvements in achieving that.
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