HC 1048-III Health CommitteeWritten evidence from DrugScope (PH 147)
About DrugScope
DrugScope is the UK’s leading independent centre of expertise on drugs and drug use and the national membership organisation for the drugs field, with around 500 members. It also incorporates the London Drug and Alcohol Network (LDAN). DrugScope is a registered charity (charity number: 255030).
Further information about our work is available on the DrugScope website at www.drugscope.org.uk
Summary of Key Points
It is proposed that the public health service will assume responsibility for the current spend of about £1 billion a year on drug and alcohol treatment services - approximately one quarter of the public health budget, and as much as half of the budgets of local Directors of Public Health (DoPH).
The specific “ring fence” is due to be removed from the nationally allocated drug treatment budget as it is integrated into the wider public health budget.
In 2012 the National Treatment Agency for Substance Misuse will be abolished and Public Health England and DoPH will take responsibility for ensuring a range of specialised health interventions of an appropriate quality are available for people with drug and alcohol problems.
There is overwhelming evidence that properly funded and evidence-based drug and alcohol treatment delivers substantial benefits for individuals, families and carers, local communities, society and the economy. This applies to the whole range of services required for a balanced treatment system, from needle exchange programmes to abstinence-based residential programmes.
The success of the public health reforms will be critical to the delivery of the ambitions set out in the Drug Strategy 2010, with a greater emphasis on recovery and social re-integration, and other areas of Government policy (including criminal justice and welfare reform).
Bringing drug and alcohol policy into a broader public health remit creates opportunities for innovative approaches that can support the delivery of these policy objectives. DrugScope particularly welcomes the potential for more focus on prevention and early intervention, greater flexibility to respond to local needs and priorities and improved integration of drug and alcohol services.
DrugScope welcomes the commitment in the “Healthy Lives, Healthy People” White Paper that the NHS Constitution will apply in full to public health, including, by implication, the provision of drug and alcohol services.
There is, however, concern among DrugScope’s membership about the very limited reference to and detail about drug and alcohol services in the recent public health consultation; what is perceived as a lack of adequate engagement with this aspect of public health in planning and preparation in some local areas; and the risk of significant disinvestment in drug and alcohol services and supporting recovery. We note, for example, that in the Government consultation document on outcomes for public health only two of over 60 proposed outcome indicators were directly concerned with drug and alcohol services.
We believe the Health Select Committee’s Inquiry provides an opportunity for public scrutiny of this critical aspect of the public health reforms.
DrugScope’s Response
1. The Government’s proposals for public health are critical for the future of drug and alcohol policy and treatment in England, and the delivery of prevention and early intervention programmes. Success will be crucial to the delivery of the outcomes described in the Drug Strategy 2010 (Reducing demand, restricting supply, building recovery), and to other areas of Government policy – for example, crime reduction and reducing re-offending, and the DWP’s Work Programme and its success in supporting people affected by drug and alcohol problems off benefit and into education, training and work.
2. The public health service will assume responsibility for around £1 billion of current drug and alcohol spending. This will account for a quarter of its overall budget, and as much as 40% to 50% of the public health budgets controlled by local authorities and DoPHs.
The Role of Drug and Alcohol Services and the Risk of Disinvestment
3. The allocation of £570 million of central government funding for community and prison-based drug treatment by the Department of Health for 2011-12 was a welcome signal of the Government’s commitment to maintain funding during a period of financial austerity. There is strong support in the drug and alcohol sector for the greater focus on recovery and social reintegration in the 2010 Drug Strategy. However, a concern among DrugScope members is that the proposed transfer of an estimated £1 billion of drug and alcohol money into the public health service, and removal of the specific “ring-fence” around the “pooled drug treatment budget”, could result in significant disinvestment. One DrugScope member who contacted us expressed concern that “without ring-fencing it is difficult to discern what aspects of public health may be prioritised” (and expressed particular concerns that “clients with complex needs etc will not be specifically catered for”).
The National Audit Office’s “Tackling Problem Drug Use” (2010) concluded that £1 invested in drug treatment resulted in savings of £2.50 from reduced criminal justice, health and social costs.
4. The Drug Sector Partnership (DrugScope, Adfam, EATA and The Alliance) has developed a “Drug Treatment Consensus Statement” supported by over 70 organisations involved in delivering drug and alcohol services. It concludes that “decision makers and opinion formers have a responsibility to make sure that taxpayers “money is spent wisely, on services that deliver on public priorities and with public benefits. We recognise that tough decisions need to be made between competing priorities, particularly at a time of spending restraint. But we also know that disinvestment in drug and alcohol treatment services will leave some of the most excluded and marginalised in our society with no second chances and no route back. It will also result in greater costs in the long run”.
A DrugScope/ICM public opinion poll reported in February 2009 that nine out of ten respondents (88%) agreed with the statement that drug treatment should be available to anyone with an addiction to drugs who is prepared to address it.
Available at http://www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/MarcusreportICM.pdf
5. There is a particular challenge in ensuring the provision for people affected by drug and alcohol problems is given sufficient priority at local level when there will be competing demands on public health funding, particularly given the levels of stigma they (and their families) can experience. Drug and alcohol dependency often develops in response to problems in people’s lives, such as childhood neglect and abuse, trauma, mental health issues and experience of social exclusion (for example, homelessness or loss of employment). Despite this, drug and alcohol problems can be viewed or represented as largely self-inflicted. There is a broader challenge for Government in an age of localism of ensuring that services for the most marginalised sections of the community receive sufficient continued investment, particularly at a time when there are overall significant reductions in local authority budgets. A particular concern has been expressed by DrugScope members about local disinvestment in services for young people with drug and alcohol problems.
The NTA’s Chief Executive, Paul Hayes, has expressed concerns about local disinvestment in a letter announcing the central allocations for drug treatment spending for 2011-12 (11 February 2011): “The biggest threat to those ambitions [ie for a recovery-orientated drug and alcohol treatment system] is the potential for local disinvestment. With the impending abolition of PCTs and severe budgetary pressures on local authorities, there is legitimate concern across the treatment field that the vital funding provided from local sources will be squeezed”.
A telephone survey conducted by DrugScope’s London Drug and Alcohol Network (LDAN) (January/February 2011) reported that out of 18 young people’s drug and alcohol treatment providers contacted in the capital, only three saw their service’s current funding situation as “safe”. Of those respondents who had been informed of definite cuts in their funding, most expected reductions of around 40%, although one service was facing cuts of up to 75%.
Opportunities and Potential Reallocations of Funding
6. The potential benefits of a public health approach to drug and alcohol issues include the opportunity for an increased focus on prevention and early intervention, greater flexibility to respond to local needs and priorities, and opportunities for engagement with a wider range of drug-related health problems (including poly-drug use) and improved integration of drug and alcohol policy and services.
7. We anticipate within the new public health framework some reallocation of spending within available drug and alcohol funding – for example, increased investment in alcohol treatment and prevention. DrugScope has suggested that Government supports a programme of national and regional events for public health and other local partners to facilitate discussion of their role in drug and alcohol treatment, including contingency planning to explore the possible consequences of alternative allocations of drug and alcohol budgets.
8. There is the opportunity for more local investment in public health campaigns, but it is vital that Public Health England provides guidance and support for “what works” in this area. For example, evidence suggests that “shock tactic” public campaigns are generally ineffective and a poor use of public money unless they address a particular public health issue and are consistent with the everyday experiences of their target audience (as applied to the more successful drink driving, smoking and HIV/AIDs campaigns). Similarly, there is no evidence that simplistic “just say no” approaches to drug education are effective for prevention.
Putting Drug and Alcohol Issues at the Heart of Public Health
9. There is concern among DrugScope’s membership about the limited reference to drug and alcohol services in the Government’s “Healthy Lives, Healthy People” (HLHP) consultation documents, and in the wider public discussion of health reform. Despite the fact that drug and alcohol treatment and other services will represent a quarter of the national and up to half of the local public health spend, the White Paper contained only a handful of references to drugs and alcohol.
In 2009–10 there were estimated to be over one thousand services supporting drug treatment in England, employing over 11,000 people, accessed by 206,000 adults with serious drug problems and nearly 25,000 under 18s.
Based on NTA figures
10. Only two of over 60 proposed indicators in the consultation document on “Transparency of Outcomes” were directly concerned with drugs and alcohol:
“numbers leaving drug treatment free of dependency”; and
“rate of hospital admissions per 100,000 for alcohol related harm”.
We understand that the final public health outcomes framework will consist of around 15-20 indicators. Even so, consideration of only two drug and alcohol outcomes is not proportionate to either their contribution to the overall public health budget or their importance for Government policy. DrugScope members have reported concerns about what is perceived as a low level of engagement in, and understand of, drug and alcohol issues for emerging public health structures in some localities.
Supporting Recovery
11. A key challenge for public health will be to integrate the delivery of drug and alcohol services through public health structures and the wider recovery and reintegration ambition set out in the Drug Strategy 2010. It is important that public health is integrated into recovery-orientated approaches to local service delivery, which will be developed as part of the NTA’s Action Plan for 2011-12 and the follow up to the NTA’s “Building Recovery in Communities” consultation.
The 2010 Drug Strategy set out eight “best practice outcomes” for “successful delivery of a recovery-orientated system”:
Freedom from dependence on drugs or alcohol;
Prevention of drug related deaths and blood borne viruses;
A reduction in crime and re-offending;
Sustained employment;
The ability to access and sustain suitable accommodation;
Improvements in mental and physical health and well-being;
Improved relationships with family members, partners and friends; and
The capacity to be an effective and caring parent.
12. Health and Wellbeing Boards (HWBs). The proposed “minimum membership” of HWBs comprises elected representatives, GP Consortia, DoPH, Directors of Adult Social Services, Directors of Children’s Services, local Healthwatch and, where appropriate, the NHS Commissioning Board. The 2010 Drug Strategy suggests that membership might be expanded locally to include Police and Crime Commissioners, employment and housing services and prison and probation to provide local leadership on recovery. How far it is practicable to expand HWBs in this way is questionable, but getting the relationship between public health and recovery and reintegration structures right will be critical. (We believe that the statutorily required membership of HWBs should also include appropriate representation for the voluntary and community sector.)
13. Police and Crime Commissioners (PCCs). There is a need for clarity about the relationship between public health and PCCs. Our understanding is that PCCs will assume responsibility for some of the funding for the Drug Intervention Programme and for core Community Safety Funding (including Young People’s Substance Misuse funding). Decisions made by local DoPH and HWBs will have a significant impact on drug and alcohol-related crime, but PCCs will be democratically accountable for crime rates. There may be an argument that it would be more appropriate for the PCCs to assume overall responsibility for offender health (including drug and alcohol treatment).
14. Prisons and the community. The issue of responsibility for prison treatment and the relationship between prison and community services is also critical. DrugScope welcomed the decision to transfer the budget for prison drug and alcohol services from the Ministry of Justice to the Department of Health, included in the 2010 Drug Strategy. The HLHP consultation paper suggested, however, that the funding and commissioning routes for prisons (with responsibility resting with the NHS Commissioning Board) may be different from those for community services. We would welcome clarification on how public health reforms will co-ordinate support across the community and criminal justice system.
15. Payment by results. “Payment by results” was not discussed in the HLHP consultation, although the Government is planning to launch eight “Drug Recovery Payment by Results” pilots in September/October 2012. We are seeking clarification on the relationship between the development of payment by results approaches and the public health reforms. Issues relating to the pilots include the proposed exclusion from services paid by results of people with a dual diagnosis.
16. Harm reduction. The introduction of needle exchange and related services in the UK in the 1980s and 1990s resulted in one of the lowest rates of HIV infection among injecting drug users (at around 1%) in the world. We have asked for further clarification from Government on what requirement (if any) it is envisaged there will be for DoPH to provided services such as needle exchange, screening and testing for blood borne viruses and vaccination and treatment for hepatitis and other health problems associated with the use and administration of drugs, or what alternative arrangements are proposed for these vital services. We are also unclear what role and/or responsibilities are envisaged for GP Consortia in the provision of harm reduction services, and drug and alcohol treatment more generally.
The NHS Constitution
17. DrugScope welcomed the statement in the HLHP White Paper that the NHS Constitution will apply to the public health service. This will help to ensure provision of drug and alcohol services is meeting an acceptable standard across the country (for example, by providing access to interventions and treatments recommended by the National Institute for Clinical Excellence), by requiring all local areas to invest from public health budgets to ensure they meet their responsibilities within the NHS Constitution. We have asked for further clarification from Government of the responsibilities under the NHS Constitution, particularly as we understand that DoPHs will be employed by the local authority rather than PHE.
Dual Diagnosis and Multiple Needs
18. DrugScope has a particular concern about services for people with co-occurring substance misuse and mental health problems (“dual diagnosis”). Health reform provides an opportunity to improve integration of substance misuse and mental health services, but there is a risk of the unintended emergence of new “gaps” between services. We have called on Government to “trouble-shoot” the plans for public health to assess the impact on people with “dual diagnosis”.
Conclusion
19. The future of drug and alcohol services is one component in a much wider programme of health reform, but it is vitally important for the whole community to get it right. Public health reform presents opportunities to improve the effectiveness of local interventions and responsiveness to the issues of greatest concern to local communities. Drugscope has concerns, however, that the removal of “ring-fencing” from the drug budget, the shift of responsibilities from the NTA to the new public health structures and a more localist approach could result in disinvestment in drug and alcohol services, with a negative impact on vulnerable individuals, families and communities, and ultimately a substantial additional cost to the taxpayer. We recognise that there is potential for “efficiency savings” and scope for improving delivery within existing budgets, but there are also limits to the capacity to do this.
20. There needs to be a sufficiently robust national framework of accountability for drug and alcohol services to ensure that the levels of investment that are needed to deliver the outcomes in the 2010 Drug Strategy and to comply with the NHS Constitution are available in every area.
21. DrugScope has called for a separate consultation to ensure a full public discussion of the transfer of responsibility for drug and alcohol services to public health. This would cover issues such as transitional arrangements, the future role of local drug partnerships, skills and workforce development, accountability frameworks for DoPHs, the application of the NHS Constitution, the role of HWBs, the role of payment by results, and the integration of public health reform, criminal justice reform (including the PCCs) and recovery (from recovery champions and mutual aid to housing, training and employment). We welcome the opportunities provided the Health Select Committee inquiry to highlight the issues.
June 2011