Public Health - Health Committee Contents

Written evidence from the National Treatment Agency for Substance Misuse (PH 04)


1.  This paper is the National Treatment Agency for Substance Misuse's (NTA) formal written submission to the Health Select Committee inquiry into Public Health.

2.  It considers the issues and implications of government proposals from the perspective of alcohol and drug treatment in England.

3.  The NTA is a National Health Service (NHS) special health authority, established to improve the availability, capacity and effectiveness of drug treatment in England. We aim to help people overcome their addiction and regain their lives.

4.  We are sponsored by the Department of Health, but work closely with and are accountable to other government departments which are partners in the drug strategy including the Home Office, Ministry of Justice, Department of Work and Pensions, and the Department for Education.

5.  The NTA works in partnership with a range of organisations and agencies at national and local levels including government departments, local drug treatment partnerships (the bodies that commission drug treatment), drug treatment services in both the NHS and voluntary sector, service users and carers.

6.  The arms length body review,[1] published in July 2010 announced that the NTA would be abolished as a statutory organisation and its functions would be transferred to the new Public Health Service by April 2012.


The NTA welcomes the opportunity to give evidence to this inquiry. Drug and alcohol misuse is a major public health issue that also cuts across many other areas of policy and practice, both national and local.

The 2010 Drug Strategy tasked the NTA to support the development of a recovery-based drug treatment system, and build a role to improve the provision of services for severe alcohol dependence.

Recovery from drug addiction benefits public health and cuts crime, as well as delivering value for money for the taxpayer. Every pound spent on treatment delivered £2.50 worth of benefit to society, mostly by cutting crime but also in reduced health and social costs.

We believe the creation of Public Health England at a national level, to support and oversee local commissioning arrangements for drugs and alcohol services, is the best vehicle for taking forward the government's ambition of recovery for people dependent on alcohol or drugs.

This ambition will also require work across housing, employment, education, children services, families, criminal justice, and communities as well as treatment services.

Transferring the NTA's critical functions into Public Health England (PHE) will provide expert support for local authorities as they exercise their new alcohol and drug commissioning responsibilities.


—  Drug treatment cuts crime (preventing millions of crimes a year) and therefore delivers benefits for society and communities as well as individuals.

—  The wider public health benefit to society (reducing drug-related deaths and preventing the spread of blood-borne viruses) is as significant as the personal gain for patients (207,000) in treatment.

—  There is a legitimate cross-government interest in drugs, for which the Home Office has lead responsibility but in which MoJ, DWP, DfE, DCLG and Cabinet Office all have an interest as well as DH.

—  Government spending on drug treatment alone (£800m pa) represents value for money, because every £1 invested generates £2.50 worth of savings (HO research 2009, endorsed by the NAO 2010).[2], [3]


7.  The government's 2010 Drug Strategy[4] set out a new ambition for anyone dependent on drugs or alcohol to achieve recovery and lead a drug-free life. Its overarching aims are to reduce illicit and other harmful drug use, and increase the numbers recovering from their dependence.

8.  The strategy outlined plans to create a system that not only gets people into treatment for dependency, but also gets them into recovery and off drugs for good. The mechanism for achieving this transformation anticipated changes proposed in the government's reforms to the NHS and healthcare system. This envisages effective action at local authority level led by local Directors of Public Health (DsPH), coupled with a streamlined national public health service, Public Health England (PHE).

9.  As part of this programme the National Treatment Agency for Substance Misuse (NTA) will cease to exist as a separate organisation in 2012, and its key functions will be transferred to PHE. In the meantime, the Drug Strategy tasked the NTA to support the development of a recovery-based treatment system, and build a role to improve the provision of services for severe alcohol dependence.

10.  The transformation from a treatment system to a recovery system demands a culture shift among practitioners and providers, which accepts that treatment is only the first step on the road to recovery. Achieving long-term recovery requires substantial change across the sector, including greater engagement with housing, employment, children's services, families, and communities. This challenge was enshrined in a public consultation on a new national framework for the field, entitled Building Recovery in Communities,[5] which closed last month.

11.  The landscape in which drug treatment and recovery services operate is thus poised to change dramatically. With a new direction of travel at strategic level, and different delivery arrangements on the ground, key decisions about the size and shape of the system are moving from a national stage to a multitude of local theatres.

12.  In the wake of the government's listening exercise on the NHS, the NTA welcomes the opportunity to give evidence to this inquiry. Drug and alcohol misuse is a major public health issue that also cuts across many other areas of policy and practice, both national and local.

13.  We believe the creation of PHE at a national level, to support and oversee local commissioning arrangements for drugs and alcohol services, is the best vehicle for taking forward the government's recovery ambition. Transferring the NTA's critical functions into PHE will provide the immediate expert support (provision high-quality data, analysis and interpretation of the evidence base) for DsPH as they exercise their new alcohol and drug commissioning responsibilities.

14.  We know that realising the coalition government's new ambition of recovery for anyone dependent on alcohol or drugs will require work locally across housing, employment, education, children services, families, criminal justice, and communities as well as in treatment services. That is why it makes sense in principle to give new alcohol and drug commissioning responsibilities to Local Authorities, operating through DsPH and supported by Health and Wellbeing Boards (HWBs). This arrangement has the potential to improve the joint working required to tackle the wider physical, mental and social needs of alcohol and drug misusers necessary for achieving recovery.


15.  About a third of the UK population[6] admit to taking drugs at some stage in their lives, but few people go on to develop problems. There are an estimated 320,000 heroin and crack cocaine users in England,[7] and an unknown number of other people whose misuse of dangerous drugs poses problems not only for themselves but also for society. Almost 1.5 million adults are significantly affected by a family member's illegal drug use.

16.  Although the Drug Strategy is committed to reducing all illicit drug use, most treatment and recovery services focus on overcoming dependency, the most serious manifestation of drug misuse. Drug dependency is a health disorder with social causes and consequences. In medical terms, it is a chronic condition characterised by relapse and remission.

17.  However, it does not fit the popular medical stereotype of diagnosis, treatment, and cure, since there is no instant remedy. Many services are provided by the NHS, but increasingly they also come from the voluntary sector, with clinical expertise provided by specialist GPs and addiction psychiatrists.

18.  While any problem drug use has serious consequences, cocaine and heroin are the most damaging illicit drugs in terms of their health impact and social cost. The government acknowledges that drug dependency is a key factor in crime, family breakdown and poverty, which together cause misery and pain to individuals, destroy families, and undermine communities.


19.  Drug misuse is associated with significant public health harms, although the public health system in England has a good track record of addressing them.

20.  Up to 10% of all new HIV infections worldwide occur through injecting drug use, and current or former injectors are also particularly vulnerable to the hepatitis C virus. The HIV rate among English injecting drug users (IDUs) is currently less than 2%, and new diagnoses in the UK are the fourth lowest in Western Europe.[8], [9], [10]

Nevertheless, NICE estimates that the combined crime and healthcare costs of each IDU adds up to £480,000 over their lifetime.[11]

21.  About a third of IDUs report an abscess, open wound, or sore as a result of risky and un-hygienic injecting practice. Estimates of the annual healthcare costs associated with injection site infections range from £15 - £47 million per year, mostly in hospital admissions for treating MRSA and severe bacterial infections.[12]

22.  Heroin users run a high risk of premature death through overdose, particularly through injecting.[13] This pattern is found worldwide, and in many countries (including the UK) deaths from drug misuse account for as many deaths as road traffic accidents among males. Research also shows that addicted prisoners are at increased risk of drug-related death in the weeks immediately after release.[14], [15]

23.  So if public health is about preventing disease, prolonging life and promoting health, then tackling dependency on dangerous drugs is a classic public health issue. Successive governments have recognised the risk to society of spreading blood-borne viruses through injecting, the prospect of premature death from overdose, and the damage individuals do to their health and well-being by misusing drugs.

24.  However if clinical need was the only criteria for investment, drug misuse would not be top of the healthcare priority list. The annual toll from drug-related deaths - 1,700 - is relatively small besides, say, the 115,000 people who die every year from smoking-related diseases. The case for tackling drug dependency rests also on the wider social impact of drug misuse.[16]


25.  According to research endorsed by the Home Office, problem drug use costs society £15.4 billion a year, of which £13.9 billion is attributed to crime committed by drug dependent offenders.[17]


26.  Addicted drug users commonly commit acquisitive crimes such as shoplifting, burglary or robbery to fund their habit. Some also take up other economically motivated crimes such as prostitution, while others resort to begging. The illicit drugs market often uses violence to regulate itself, and the fact that drugs can reduce inhibitions and increase aggression means that drug use is linked to anti-social behaviour and violent crime. Factor in drugs law offences, drug driving and money laundering, and drug misuse contributes significantly to the crime burden and policing costs of any local area.

27.  Between one-third and a half of acquisitive crime is estimated to be drug related. Recent research (2008) which matched anonymised data from the Police National Computer to information in the NDTMS, showed that the total number of crimes committed almost halved following the start of treatment.[18]

Safeguarding vulnerable children

28.  Parental substance misuse is a significant risk factor for children. About one in every hundred babies are born each year to women with serious drug problems.[19] About three out of every hundred children under 16 have parents with problematic drug use (although not all these children will be actually living with their parents). The problem drug use of other family members such a parent's new partner, siblings, or other individuals within the household also put children at risk of significant harms, including prejudicing their educational attainment.

Families and communities

29.  Serious drug problems profoundly impact on the family members and carers of drug users. A drug problem often hits family finances and can lead to feelings of anxiety, worry, depression, helplessness, anger and guilt among family members.[20] The stigma associated with drug addiction within the family often means that affected family members are reluctant to seek professional help.

30.  Drug misuse also fuels welfare dependency, worklessness and social exclusion and has a negative impact on local communities who face a rise in anti-social behaviour and higher levels of crime. Deprived areas usually suffer most, frequently becoming a focus for drug dealing that can fuel a cycle of decline and lead to heightened levels of fear and intimidation among local residents.

A cross-government response

31.  Reducing both the problems caused by illicit drugs misuse and the adverse health and crime outcomes associated with it has been a key policy goal since the threat of HIV/AIDS came to public attention in the1980s. While the Home Office has lead responsibility for drugs policy, and the Department of Health pays for healthcare and treatment services, other departments have a legitimate interest in aspects of the subject - notably MoJ, DWP, DfE, DCLG and Cabinet Office. The rationale for creating the NTA as a special health authority in 2001 was to ensure that NHS funds were spent on providing services whose primary benefit was crime reduction. Currently the Inter-Ministerial Group on Drugs, chaired by the Home Office drugs minister, exercises cross-government scrutiny of all strands of the Drug Strategy.


32.  Addiction is treatable, but no single treatment is appropriate for everyone. For example, substitute prescribing is recommended by doctors as the first-stage treatment for heroin addiction, but is not available for cocaine addiction. Good treatment attends to the medical, psychological, and social needs of patients with a balance of pharmacological and psycho-social interventions. Drug workers seek to get addicts better and to help them become free of dependency. They also support addicts to be active citizens, take responsibility for their children, earn their own living, and keep a stable home. Hence treatment is the first step on the road to recovery.

33.  The Government currently spends about £800 million a year to ensure a balanced range of drug services in the community in line with the evidence of what works. About 70% of the funding comes from the centre through the pooled treatment budget, the rest is supplied locally by Primary Care Trusts (PCTs) and Local Authorities. In addition about £200 million is made available for alcohol treatment directly through PCTs. There is separate funding for treatment in prisons.

34.  Provision is currently commissioned by 149 local partnerships, originally called Drug Action Teams but increasingly known as Community Safety Partnerships, representing health, local government, police and probation. Under the government's plans, the commissioning role will migrate to Local Authorities supported by Health and Well-Being Boards.

35.  The Government has indicated PHE would have a ring-fenced budget of at least £4bn to allocate to the expanded public health role of local authorities.

36.  An investigation by the National Audit Office in March 2010 acknowledged that treatment delivers value for money for the taxpayer. It cited the Home Office research finding that every pound spent on treatment delivered £2.50 worth of benefits to society, mostly by cutting crime but also in reduced health and social costs.[21]

37.  Three-quarters of the public believe drug treatment is a sensible use of taxpayers' money, as long as it benefits individuals, their families and communities. But if they have to choose, most people say the greatest benefit of drug treatment is that it makes their communities safer and reduces crime.[22]

May 2011

1   Department of Health (26 July 2010) Review of arm's length bodies to cut bureaucracy. Back

2   Home Office (2009) The Drug Treatment Outcomes Research study (DTORS): Cost-effectiveness analysis. Home Office Research Report 25. Back

3   National Audit Office (2010) Tackling problem drug use. Back

4   HM Government (2010) Drug Strategy 2010. Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life. London: Home Office. Back

5   NTA (2011) Building recovery in communities: A consultation for developing a recovery-orientated framework to replace Models of Care. Back

6   Home Office (2011) Drug misuse declared: findings from the 2009/10 British Crime Survey. Back

7   Gordon, L, Tinsley, L, Godfrey, C and Parrott, S (2006). "The Economic and Social Costs of Class A Drug Use in England and Wales, 2003/04" in Singleton, N, Murray, R and Tinsley, L (Eds) Measuring Different Aspects of Problem Drug Use: Methodological developments. 2nd Edition. Home Office Online Report 16/06. London: Home Office. Back

8   HPA (2010) Data tables of the Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in Injecting Drug Users. Surveillance Update: July 2010. Back

9   HPA (2010) HIV in the United Kingdom: 2010 Report. Health Protection Report (Volume 4 Number 47). Back

10   Harm Reduction International (2010) Global State of Harm Reduction 2010: Key issues for broadening the response. Back

11   NICE (2009) Needle and syringe programmes: providing people who inject drugs with injecting equipment, NICE public health guidance 18. Back

12   HPA (2009) Shooting Up: Infections among injecting drug users in the United Kingdom 2008. An update: October 2009. Back

13   Romina L Gaston et al (2009) Can we prevent drug related deaths by training opioid users to recognise and manage overdoses? Harm Reduction Journal 2009, 6:26 doi:10.1186/1477-7517-6-26. Back

14   Department of Health (2010) The Patel Report: Prison Drug Strategy Review Group. Back

15   Merrall EL et al (2010) Meta-analysis of drug-related deaths soon after release from prison. Addiction, 2010 Sep; 105(9):1545-54. Epub 2010 Jun 23. Back

16   Office for National Statistics (2010) Statistical Bulletin: Deaths related to drug poisoning in England and Wales, 2009. Back

17   Christine Godfrey et al (2002) The economic and social costs of Class A drug use in England and Wales, 2000. Home Office Research Study 249. Back

18  Tim Millar et al (2008) Changes in offending following prescribing treatment for drug misuse. NTA. Back

19   Department of Health FOI response, September 2009. Using Hospital Episode Statistics from the Information Centre for health and social care. Back

20   Orford, J et al (2005). Coping with Alcohol and Drug problems: The experiences of family members in three contrasting cultures. London: Taylor and Francis. Back

21   National Audit Office (2010) Tackling problem drug use. Back

22   Findings from an NTA commissioned MORI survey of public opinion in 2009. Back

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© Parliamentary copyright 2011
Prepared 2 November 2011