Written evidence from the National Treatment
Agency for Substance Misuse (PH 04)
INTRODUCTION
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.
EXECUTIVE SUMMARY
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.
KEY FACTS
— 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]
THE 2010 DRUG
STRATEGY
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.
THE NATURE
OF THE
PROBLEM
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.
DRUGS AND
PUBLIC HEALTH
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]
DRUGS AND
SOCIETY
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]
Crime
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.
TREATMENT AND
RECOVERY SERVICES
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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