Session 2012-13
Publications on the internet
Home Affairs Committee - Drugs: Breaking the Cycle - Conference held in Portcullis House on Monday 10 September 2012
HOUSE OF COMMONS
HOME AFFAIRS COMMITTEE
INTERNATIONAL CONFERENCE ON DRUG POLICY
MONDAY 10 SEPTEMBER 2012
MAJOR-GENERAL LEÓN RIAÑO
DR ALEX STEVENS
NICOLA SINGLETON and ANGELA PAINTER
PROFESSOR NEIL MCKEGANEY, JAN PALMER, GARY MONAGHAN and MARK JOHNSON
MR MEKKI el-HANKOURI
DR LEAL da COSTA
Oral Evidence
Taken before the Home Affairs Committee
<?oasys [ep[fyFrutiger,Bold,11,21] ?>Conference held in Portcullis House on Monday 10 September 2012<?oasys [rs ?>
The Committee held an international conference on drugs at Westminster on 10 September 2012.
The following transcript of the plenary session was reported to the House as written evidence on
3 December 2012
Members of the Home Affairs Committee present:
Keith Vaz (Chair)
Nicola Blackwood
Dr Julian Huppert
Alun Michael
Bridget Phillipson
Mark Reckless
________________
Q1 Chair: Good morning, participants and parliamentarians. I welcome you most warmly to this international conference that has been called by the Home Affairs Select Committee. I begin by introducing the members of the Committee who are here today: Dr Julian Huppert, Mr Mark Reckless, Bridget Phillipson, Nicola Blackwood and Alun Michael. They represent different constituencies across the United Kingdom. This Home Affairs Committee was constituted in 2010. For those of you not familiar with our Committee system, its purpose has been to scrutinise the actions of the Home Office, and to make recommendations about areas of policy.
In particular, I thank Dr Julian Huppert, the Member of Parliament for Cambridge, for suggesting that we have this inquiry into drugs, supported fully by other members of the Committee. The last time the Select Committee looked at the issue of drugs was 10 years ago, when the Prime Minister was, in fact, a member of our Committee, so the Committee felt that a decade later, it was probably timely to look at the subject again.
I thank everyone for coming here today. Some of you have travelled many miles in the United Kingdom; some have travelled many thousands of miles. In particular, I welcome the head of the Colombian National Police, General León, who has travelled from Bogotá and arrived yesterday, and Dr Leal da Costa, the Portuguese Minister of Health, but all of you are most welcome. We have people here from the United States through to France, and from Brazil through to Yemen. That gives you an indication of how important and how dangerous the issue of drugs is.
The outcome of this conference will feed directly into our inquiry on drugs. We are very interested in your comments and your experience; because of the way in which the Select Committee system operates, it is just not possible to have everybody coming before us to give oral evidence to the Committee, which is why we were very pleased to see more than 200 submissions from individuals and organisations on this subject. I thank the Home Affairs Committee staff because they, along with us, have had to read the submissions and-I was going to say make sense of them, but they are all very sensible-try to decide which ones should carry weight and which ones should be included in our inquiry.
As well as having international speakers, we have some speakers today who will help us, in our workshops, to lead further discussions. I should say, in the traditional way of the British police, that <?oasys [pc10p0] ?>everything you say will be taken down and used in evidence, not necessarily against you, but certainly to assist the Committee.
The use of drugs has existed for several thousand years. Traditional drug use was limited largely to special religious and social events, and to medical use. Opium and cannabis have long been used in Asia, and later in Africa and Europe. The same is true of the coca leaf, and of khat in countries such as the place of my birth, Aden in Yemen. However, in the last century, the use of drugs has become a growing and legitimate public health concern.
The first conference of the International Opium Commission was held in Shanghai in 1909; it was followed by the adoption of the international opium convention, signed at The Hague in January 1912. Three drug control conventions were adopted under the League of Nations in the inter-war period and, finally, the three United Nations drug control conventions were adopted in 1961, 1971 and 1988. Despite more than a century’s work to stop the flow of drugs, we have at most stabilised rather than reduced the number of illicit drug users. Only two months ago, the UNODC released figures showing that the global number of illicit drug users is likely to grow by 25% by 2050 to 287.5 million. The bulk of the increase is expected to take place among the rapidly rising urban population of developing countries. This presents a new set of difficulties for those committed to the eradication of harmful drug use.
The harms that stem from drug use are not just the danger of addiction or its effect on physical health. In the United Kingdom alone, drug addicts commit between a third and a half of all acquisitive crime. Drugs are costing our health and justice service about £15.3 billion a year. While they are dangerous, the harms of drugs extend far beyond the addict in the consumer country, who is knowingly being sold a product that is contaminated with many adulterants. There are harms to farmers in the source country who have their crop destroyed because they are also growing coca leaf or opium. Three Andean countries, Colombia, Peru and Bolivia, are responsible for virtually all global coca leaf production-the raw material for cocaine. In 2010, coca was cultivated on 149,100 hectares in those three countries, an area roughly one and a half times the size of Hong Kong. There are harms to the political leadership in the transit countries, which cannot combat the drug traffickers because their national budget is dwarfed by the money available to those who smuggle illicit <?oasys [pc10p0] ?>drugs. The value of the global cocaine market is £543 billion, while Bolivia’s national budget, for example, is only around £1.69 billion.
The harms of illicit drugs are varied and have dire consequences. It is estimated that more acres of the Colombian rain forest are cleared to plant coca leaf than are cleared for use in all farming. Despite the damage to their land, which the Committee witnessed first hand in Colombia, Andean farmers receive only 1% of the revenue from global cocaine sales, yet we are rarely able to discuss the environmental impact of drug use. In West Africa, we are seeing the emergence of the world’s first narco-states, yet how often do we discuss the implications of drug use? All kinds of harms have occurred, but we are particularly concerned about the huge increase in addiction to prescription drugs, which we saw for ourselves when we visited Miami; that is something that we fear may happen in this country.
As we saw when the Home Secretary appeared before the Home Affairs Committee last Thursday, we are also very worried about the increase in legal highs. There are 41 new substances discovered every year in the United Kingdom to do with legal highs. In 2011, a new substance was discovered almost every week. Such substances, I am afraid, have unknown health effects. We have to deal with these problems and face them together.
At the end of the last Session of Parliament, the former Lord Chancellor, Ken Clarke, still a member of the Cabinet, told the Committee that he felt that we had lost the war on drugs. The Home Secretary, when she appeared before the Committee last Thursday, expressed a great deal of concern about the need to join up various parts of Government, not just in this country, but internationally. We cannot reach a solution on our own. That is why the Committee decided to hold this international conference. We have brought together representatives of Colombia, people from Guinea-Bissau in West Africa, the Health Minister from Portugal, and, of course, parliamentarians and other groups from the United Kingdom. I do not believe for one moment that we can solve this problem on our own. The only way to solve this problem is if we all work together.
I hope we have a very productive conference. The Select Committee does not have answers yet. We are still in the process of looking at the evidence. Very shortly, we will have a discussion as to our recommendations, and we hope to have a report ready-the first such report in 10 years-by Christmas this year. I hope that you will speak freely. No one is going to shout you down-this is not a session of the British Parliament. This is an opportunity for us really to hear what you have to say, and to learn, so we are keen to listen to you. I hope you will use this as an opportunity for taking this cause further.
I was very interested to hear from five parliamentarians who have come from Morocco just before we began our session. It is vital that those of us who are here as Members of Parliament continue this dialogue. Of course, in the end it is up to Government, but we in Parliament have a very important role to play in ensuring this happens.
Our first speaker is one of the most senior members in the Colombian Administration dealing with drugs. General León took office last year, and this is his first international visit as Director General. He has been in the Colombian police for over 30 years and has also studied in Paris and the United States of America. Members of the Committee went to Colombia, and we met many of the Colombian generals. General Pérez is here with us today. We actually went into the Colombian jungle. Some, of course, would have hoped that the Select Committee might have stayed there, but we came back. It was astonishing to see the very young men who had volunteered to go into the jungle to fight those who are involved in cocaine. This is the front line. It is not Leicester, London, Slough, Birmingham or Leeds; the front line in the fight against drugs in our country is what is happening in Colombia. We in Britain owe them a huge debt of gratitude for what they do. Ladies and gentlemen, please welcome General León, the head of the Colombian police.
Speaker: Major-General León Riaño, Director General of the Policía Nacional de Colombia.
Major-General León Riaño: (Translation) First, I would like to greet you all cordially on behalf of President Santos and the national police. I also thank you for inviting me to share the experience of Colombia’s fight against drug dealing. For a decade, Colombia has been going through a very difficult situation, fighting against drug dealing. When engaging with international forums, other countries did not appreciate some of Colombia’s comments, but today, Colombia is seen as a point of reference on an international scale for the success it has had in the fight against drug trafficking. Our President has shown that the experience gained over three decades of fighting against this problem is now available for all countries, so that the people of other countries can avoid the same spiralling downfall experienced by some of our compatriots in Colombia. For that reason, the Colombian experience is available for everyone.
Let me show you how the fight against drug trafficking has become a national policy. Ours is one of the most solid and consistent policies in fighting drug trafficking. More than 40 state members share in the strategy. The components of action include repression; prevention; social, economic, and political aspects; and issues to do with health and the environment. The integral anti-drug policy used by the Colombian states and developed by the national Government comes under the framework of a policy called "Prosperity for Everyone". Through the Ministry of Defence, the main objective is to reduce the production of narcotics.
Among the institutional imperatives is a definitive offensive against narco-trafficking, in which we are looking to eliminate areas of drug cultivation, strengthen the capacities of interdiction, and eradicate criminal bands and drug-trafficking organisations.
Today, the mega-tendency of the anti-trafficking policy, seen from our point of view, is talking about the end of the big cartels, because drug trafficking has been transferred to armed groups. The big drug cartels have been disbanded-the Medellín cartel in 1993, the Cali cartel in 1998, and the Norte del Valle cartel in 2003. Cartels dominated drug trafficking, from cultivation to export to foreign places. All this led to a rupture in drug trafficking within the country, which led to the hegemony of drug trafficking in Colombia and in the Mexican cartels. In this fight, we have identified 17 micro-trafficking groups and approximately 42,100 consumers within the country. As a result, various networks, including FARC, the National Liberation Army, and the criminal bands, have resulted.
Cultivation and potential production has been reduced by 61% between 2000 and 2011, from about 162,510 in 2000 to 63,762 in 2011. Again, there has been a reduction in the potential production from 695 tonnes in 2000 to 345 tonnes in 2011, and an increase in the rate of effectiveness of combating drugs from 36% to 56%. As a result we have seen a drug-terrorist symbiosis. The FARC and the ELN, like the main perpetrators of drug trafficking in Colombia, have left aside their ideological profile to move on to the consolidation of economic empires that will let them maintain their illicit activities. This drug-terrorist symbiosis leads to a new threat in cocaine trafficking for the state. These narco-terrorist groups such as the FARC, the ELN and the criminal bands maintain a strong influence over drug trafficking strategies where they capitalised drug cultivations as platforms for distributing drugs internationally.
We found that the FARC control 88% of the coca plantations in the country-approximately 56,233 hectares of the 63,762 hectares that have been identified. For example, in zone number 4 the FARC controls 22,379 hectares of coca plantations. Criminal bands control approximately 26,000 hectares and the ELN controls about 15,000 hectares. To follow the development of drug trafficking between south America and Europe we have identified three routes that leave from different points within south America and transit to the Caribbean islands, central America and Africa. We have also identified two new routes in the trafficking of drugs: the Suez Canal route and the Balkan peninsula route, the latter being through Turkey, Bulgaria, Romania and Italy. That has made the Governments implement a strategy against drug trafficking, developed by the national police. It joins up all the cycles of drug trafficking-production, trafficking, money laundering and export-so that the illicit trade is less lucrative for the delinquents and criminals.
The strategic components of the policy include prevention, eradication of illicit plantations, research and operations, and control of ports and airports. The prevention of the production and consumption of drugs tackles four aspects that you can see in this slide. It is directed through social programmes, sensitising the young, teachers and parents to prevent the consumption of drugs.
The eradication of illicit plantations includes a technical and controlled eradication of crops to ensure permanent eradication; a consolidation of areas, with reduced detrimental impact; an environmental management plan; and a look-out for complaints relating to aerial fumigation.
Today we eradicate in three ways. The first is through voluntary eradication by communities, especially in rural areas. The second is manual eradication by groups that have been hired by the police and the Government, and protected by the police. Finally there is aerial fumigation, controlled by the Ministry of Environment.
With regards to the interdiction, investigative processes and operations are used to break up criminal organisations. When President Santos was the Minister of Defence he created a system of national intelligence where the various forces put together their technological capacity and intelligence to find and capture and neutralise the heads of the different terrorist groups. Among the operations that took place is Operation Phoenix which enabled the neutralisation of Raúl Reyes, the main international link of FARC and the second in command of this drug terrorist group; the Jaque operation where some Americans who had been kidnapped were freed as well as Ingrid Betancourt, a former presidential candidate; and Operation Sodom, where Mono Jojoy, the main terrorist of our country was captured
In this slide we can see the reduction in the illegal crops: in 2000 it is 162,000 hectares and with a reduction of 61% last year ending in 63 hectares. It is the lowest rate in the last 16 years in our country, which confirms the success and the sustainability of the anti-drug policy in Colombia. Today we find a new phenomenon, replantation. This slide shows the percentages of replantation in each of these zones. Thanks to the operational control that we are implementing at the moment we can see the big reduction in replantation. We can summarise this in what you can see here of the support. Today we intend to increase the basis for fumigation with the point of identifying the cycle of production and that way eradicate the illegal crops more effectively.
These contingency strategies against replantation are in three categories: fumigation, manual clearance and social programmes. We have also noticed decreasing production of cocaine in Colombia. As I have shown, it has gone down from 695 tonnes to 350 tonnes today-a reduction of more than 50%.
Colombia has always sought co-responsibility. For that reason we always look for regional alliances, and we also have alliances outside our continent. Collaboration goes beyond simple co-operation, but it is imperative in order to reduce the production of drugs. For that reason, we appeal to international co-responsibility. Through teamwork with other police forces in the world, such as Europol, Ameripol, Interpol, and the American Association of Police Officers, we managed to capture more than 30 heads of drug trafficking at the first level. They had taken refuge in places in Ecuador, Cuba and Venezuela, escaping from the police and the authorities. The result was due to co-operation with police forces in other countries. Some 1,500 policemen from abroad have been trained in Colombia.
In conclusion, I would say that our country’s position today in the fight against drug trafficking was expressed recently by President Santos in the international forum in Cartagena in Colombia, where he referred to legalisation as an alternative to research and study and as a policy that could be most effective in the fight against drug trafficking. At this time, our country continues to fight against this issue. Thank you.
Q2 Chair: Thank you very much. We now move on to our next speaker. Alex Stevens is professor of criminal justice at the University of Kent and the author of a number of important books on the subject of drugs. He is going to speak to us for about 10 minutes.
Speaker: Dr Alex Stevens, Professor of Criminal Justice, University of Kent.
Dr Stevens: Good morning. First of all, I would like to thank Mr Vaz and the other members of the Committee for this opportunity to talk to you about drug policy-my specialist subject. I am going to be talking today about Portugal and Sweden, and I imagine that this is because the examples of Portugal and Sweden are often given by opposing camps in the drug policy debate as countries that we should copy in order to solve all our drug problems, or at least see them substantially reduced. I am going to be talking today about the key features of those policies and about how the story has been told of the success or failure of those policies. I will then perhaps contrast some of the stories against the data that I am going to show you about trends since decriminalisation in Portugal and more recent trends in Sweden around drug use and drug-related harm. Finally, I want to expand the argument and make it a little more interesting, I hope, by arguing that it is not just about drug policy; we need to be thinking about other forms of policy when looking at drug policy outcomes.
I will now speak about the key features of the Portuguese policy. I imagine that we will hear more about that from Dr da Costa, so I will keep this brief. Portugal, as many of you know, decriminalised the possession of personal amounts of all illicit substances-not just cannabis-in 2001. Possessing less than 10 days’ supply is now not a criminal offence, but it remains an administrative offence, so one can still be referred to what are known as committees for the dissuasion of addiction, which can impose fines, but normally provisionally suspend proceedings in the hope that one will not return. Dealers and traffickers continue to be prosecuted. Treatment and harm reduction have also been majorly expanded. For example, low-threshold methadone maintenance services were significantly expanded by investing in them after 2001. There have also been changes in broader social policy. The Socialist Government that introduced decriminalisation also introduced a guaranteed minimum income for levels of welfare support.
The narrative of success that has been given by, for example, Glenn Greenwald from the Cato Institute is that drug use has declined, drug deaths were reduced, and Portugal has a lower prevalence of drug use than other European countries. However, he did not place much emphasis in that story on the expansion in treatment, which I consider to be very important, or on the fact that there was an increase in reported lifetime drug use among adults in Portugal after 2001. He declared the policy a "resounding success". He has an opponent in this story: Dr Pinto Coelho, who has been a long-time opponent of the policy within Portugal, said that, on the contrary, drug use went up, drug deaths went up, drug-related homicides went up, Portugal has the highest rate of HIV among injecting drug users in Europe, and the policy was therefore a disastrous failure.
So there are two stories about the same objective reality. How do we disentangle this? As a researcher, I try to disentangle things by looking at what the data say, so let’s have a look at some of the data. We have available to us a range of surveys done among young people. There are four different types of survey done at different ages of young people. You will see, however, that the general trend since decriminalisation has been a downward one among all the ages of school age. In front of the Home Affairs Committee last week, the Home Secretary mentioned this increase from 1995 to 2007, but she did not mention that the more recent trend is downwards. We also have evidence on drug-related deaths. This is a little bit confusing, because we have two indicators of drug-related death in Portugal. The grey line is based on the number of bodies where drugs are found in toxicological autopsies after the person has died. The black line is the more internationally recognised classification of drug-related death, where a physician declares that drugs had some role in the death. You will see that they both go down and then the grey line divergers go up. Dr Pinto Coelho is emphasising that line. The problem with that is that not only has the number of people found with drugs in their body when they have died gone up, the number of toxicological autopsies has gone up, so even if there had been no increase in drug-related deaths, there would have been an increase in the number of bodies found to have drugs in them. We therefore consider the black line to be a much more reliable indicator of an actual decrease in drug-related deaths in Portugal.
With regard to drug-related homicides, Dr Pinto Coelho’s statement was based on a footnote in the United Nations Office on Drugs and Crime World Drug Report, which speculated that an increase in homicides after 2001 might have been drug-related. Even if it were drug-related, where there is no clear mechanism that it would be, we are now actually down to levels very similar to those before decriminalisation, so there does not seem to be any lasting effect of decriminalisation on homicides, let alone whether they are drug-related or not.
For me, the biggest story from Portugal is the dramatic decrease in levels of HIV infection among injecting drug users-an extremely positive policy impact. The decline continued from 2008. The red bars on the graph had also continued further by 2010, according to the European Monitoring Centre for Drugs and Drug Addiction.
Let us move on to Sweden. In contrast to Portugal, which had an aim in its drug policy of bringing drug users into society and creating social solidarity, the main thrust of Swedish policy is to aim for a drug-free society. That has been the case since about 1969, when an activist called Nils Bejerot founded the Association for a Drug-Free Society, which was very successful in changing laws in Sweden and moving things in that direction. Sweden has had since the 1970s a very restrictive approach to drugs. The use of drugs is still criminalised in Sweden. Having drugs inside your body is a crime; it is not just possession of the substances. People who are arrested are very likely to face conviction, which is much less likely in Portugal and even in this country. They also have the opportunity to use compulsory treatment, to force people who don’t want to be treated for their drug problem to go to treatment, even if they have committed no other crime.
In contrast to that restrictive story, by comparison with the UK, Sweden has a relatively lenient penal approach. Several offences under the Misuse of Drugs Act here carry much longer sentences than the maximum for a first drug offence of any type, even large-scale drug trafficking, in Sweden. The other element of the Swedish situation is that there is quite limited availability of harm-reduction services. There is not much needle exchange and very little methadone maintenance provision.
According to the United Nations Office on Drugs and Crime, the story was that countries get the drug problems they deserve. If you have a restrictive approach, you will end up with low levels of drug use, making a clear cause and effect link from the restrictive approach to the low levels of drug use that Sweden observes. Other people have made counter-arguments to that: Peter Cohen in Amsterdam and Pelle Olsson in Stockholm say that the conclusions are not supported by the evidence and that recent data show increasingly worrying tendencies in drug-related death and HIV. So let’s again look at the data.
This is a graph from the United Nations Office on Drugs and Crime report, which proclaims the success of the Swedish drug policy since the 1970s in reducing drug use. One thing you will see is that Sweden did historically have very high rates of amphetamine use. You will see that there is a major reduction in the use of amphetamines. You will also see that that reduction took place before the restrictive policy happened. Therefore, the restrictive policy cannot be the cause of the effect of a significant reduction in drug problems.
There is a quite worrying tendency in Sweden towards an increase in drug-related deaths. Drug-related deaths are now the leading cause of death in Swedish cities, greater even than road traffic accidents among young men. There have also been worrying trends in HIV incidence among Swedish drug users. In 2006, an outbreak in Stockholm led to increasing surveillance, so the peak may be more to do with surveillance effects than such a dramatic increase in HIV, but there is still a worrying tendency for outbreaks of HIV in the absence of harm reduction services.
So far I have been looking at drug policies and what outcomes we might tie to an individual country’s drug policy. I want to argue that it is more interesting to look elsewhere. For example, this morning General León talked about the importance of social policy and social programmes on the drug problems that countries experience. The graph shows on the vertical axis the prevalence of cannabis use among 15-year-olds-the type of cannabis use that we would most like to reduce as it appears to be the most damaging.
On that axis, you have an index of welfare generosity-de-commodification; how much you can get services without access to the market and being able to pay for things. It is based on levels of unemployment benefit, sickness pay and pensions. We see a correlation between countries that have the least generous welfare states tending to have the highest rates of cannabis use among their population. There is also a correlation between the least generous welfare states having the highest rates of injected drug use. You will all know that correlation is not causation, but it is indicative of a relationship-a relationship that does not exist between the harshness of the enforcement of drug laws and prevalence of drug use. There is no consistent relationship across countries, as to countries with more or less harsh drug laws having consistent differences in the rate of drug use among their people or, indeed, of problematic drug use.
At least we can say from the conflicting evidence that decriminalisation in Portugal did not lead to the feared explosion in drug use. Therefore, many of the arguments put forward, for example by the Home Office, that we would expect to see a massive increase in drug use if we were to be more liberal in our drug policy are not supported by that example, at least. On the other hand, restrictive policies in Sweden did not cause the reduction in drug use. Something else was going on in Sweden that led to a reduction in quite high levels of amphetamine use, which have stayed low and stable since. But it was not about the restructured drug policy.
Treatment and harm reduction services appear to be associated internationally with reductions in HIV and drug-related deaths, but broader policies of welfare and imprisonment are a very important part of the story that is often omitted from analyses and political debate on what to do about our drug problems.
Thank you for the opportunity to give you this short run-through of some of the issues. If you want more information, it is available in the publications I have brought with me or by e-mailing me at my university e-mail address.
Chair: Thank you, Professor Stevens. We have a quick question from a member of the Committee who just happens to be your local MP.
Q3 Mark Reckless: You described Portugal and Sweden as if they were two poles in the debate. That there is a restrictive, harsher policy in Sweden, I would not question, but is it correct to portray Portugal as liberal or relaxed in its approach to drugs? One of the difficulties in the debate is that as soon as you say "decriminalisation" with respect to Portugal, people make the assumption that somehow drug use is tolerated within Portuguese society. That was not our impression on our visit. The dissuasion commissions that people are sent to seem, in many ways, to take stronger and greater action on drugs than perhaps our own criminal enforcement measures often do.
Dr Stevens: It is true to say that Portugal certainly has not shone the green light for drug users and said that everyone is free to use drugs. It still disapproves of it, but its attitude was that the criminalisation of drug users was driving a wedge between drug users and the rest of society that was not helpful in terms of integrating them into the treatment services they need. For example, treatment was seen as a better way to go than prison. Looking at the prison population in Portugal, on the graph in front of you, the blue line shows those imprisoned for drug offences. After decriminalisation, there was a significant decline in the number of people in prison for drug use, as you would expect. If imprisonment is an indicator of the harshness of drugs policy, then certainly that type of harshness reduced; at the same time, Portugal was able to integrate more problematic drug-users into treatment to create social solidarity.
Q4 Chair: That is very helpful. Thank you. We are now going on to our next panel. Could I say to Nicola Singleton and Angela Painter, whose biographical details are in the booklet, that you don’t need to come to the lectern for this? What we would like is just five minutes from each of you on the issues that you cover. Nicola Singleton is the Director of Strategy and Research at UKDPC, and Angela Painter is the Chief Executive of Kenward drug treatment.
Speakers: Nicola Singleton, Director of Policy and Research, UK Drug Policy Commission, and Angela Painter, Chief Executive, Kenward Trust.
Nicola Singleton: Thank you very much for inviting me to talk briefly about payment by results. The UK Drug Policy Commission was set up to provide objective analysis of the evidence around drug policy. For those who don’t know, we are an independent, charitably funded body. We are not part of the Government. We have considered payment by results as part of our wider work programme, so we included it in our evidence to the Committee. There is a lot that could be said about it, but I will try to be brief and concise.
Payment by results is intuitively very appealing. Who would not want to pay for good outcomes? Unfortunately, the evidence around the payment by results model is not as strong as people might think. The evidence suggests that where it works is where you have a single, very clear outcome, and you are quite clear about the interventions that will get you there, so that everybody is clear about what needs to be done, and about the outcome you are going to pay for. Unfortunately, recovery does not really tick those boxes. Recovery is recognised as a very complex and individual process. People start from different points. They have different resources themselves, and they may also have a different opinion of what recovery will mean to them. It is very hard to pay for recovery or to measure the recovery when you get to it.
There has been a good attempt, but you have ended up with nine separate outcomes as part of the payment by results recovery model. There are also a number of different complexity levels in recognising people’s different starting points. This means that you have a very complex model to work out what has to be paid to people. That will come with a whole host of costs in administering the process. One also has to wonder how the incentive works. When you have so many different payments that will all carry tiny amounts of money, how do you feel incentivised to deliver? There are questions around that.
There is also a lot more opportunity for perverse incentives. This has been shown in quite a lot of attempts at payment by results in the past, and in the forerunners to the Work programme. It was the same with targets. People focus very much on these areas that are being paid for, and they may not take a very clear overall approach to people. I will not talk about the impact on providers because I think that is what Angela will talk about, but there are issues around the risks that are being put on to the providers. I suppose one of the main dangers that we see is that the focus on the payment by results recovery has led to an expectation that this is the only game in town, and that this is the most important way of achieving greater recovery.
It is important to recognise that there has been a sort of payment by results; there has been payment for better outcomes going on through the payment system. The way in which money has been allocated to areas has already been paying for improvements in delivery. There has been an improvement that has been ongoing for some time. There are lots of other important things that are being tried out in local areas that are not directly payment by results. The evidence suggests that a good way of improving recovery outcomes is to have better-linking services, with mutual aid and peer support, which need not cost anything at all. Getting better integration of services does not have to be done through a payment system. There are also lots of different ways in which people are working to improve recovery in their areas, perhaps through setting up social enterprises, which help to sustain recovery. That is perhaps the more difficult thing-not so much achieving it in the first place, but sustaining it afterwards. There is a big concern that all the focus is on payment by results, and we will not necessarily be learning from a lot of the other good things going on in our system already.
Q5 Chair: Thank you. May I ask Angela Painter to give us a brief overview?
Angela Painter: Good morning. It is good to be here and I thank the Committee for inviting me. There are a couple of things that I want to make absolutely clear first. Kenward Trust is completely committed to the implementation of the drugs strategy. We are also committed to a whole person recovery model. We are committed to outcome-focused approaches, and we are keen to seek ways of offering efficiencies and value for money. What I want to share with you today is our particular experience of the introduction of the payment by results model in Kent and the impact on my organisation. I want to raise some cautions, like Nicola, around this particular implementation of the commissioning model within the drugs sector.
Kenward is a voluntary sector organisation. We provide residential recovery programmes. We are based in Kent, but we see individuals from around the country. We currently have a 100% occupancy rate in our main 31-bedded project, and a 98% occupancy rate in our other three projects. We provide aftercare and preventive and early intervention services for young people and adults in the community. We work with the homeless and offenders. Up until April this year, we also provided all the alcohol treatment services within West Kent and a significant amount of the drug treatment services. This was in a very high-performing DAT-drug and alcohol action team.
However, Kent DAT made the decision to decommission all the drugs and alcohol services, and they were successful in their bid to become a payment by results commissioner. We were quite excited by that, so we did a lot of work with all our stakeholders preparing for the tender. However, when we saw the financial modelling in the tender specification, our board had to take the very difficult decision that we could not sustain the financial risk involved in that particular model.
We were not alone. There were at least 20 provider organisations at the initial consultation event. My understanding is that only two large national providers eventually put in a bid, so the first point that I want to make is that in our experience, a payment by results model will exclude smaller voluntary sector providers that can provide innovative and quality services, and that will certainly have good local knowledge and good well-established relationships with all the variety of agencies that we know contribute to a successful outcome.
The second point I want to make is that I think the payment by results model is in danger of creating a huge bureaucracy involved in collecting payments. In my previous work in the NHS, I saw a similar thing happen. There is a danger of becoming target-driven, rather than outcome-focused. The biggest danger for me is that it changes the relationships that we know work towards successful outcomes. It can change the relationship between the recovery worker and the individual who is sat in front of them when they have a tariff attached to their head. It can change the relationship between a commissioner and provider when payment is involved. An extra bureaucracy of course has its own costs and its own inherent dangers.
My final point is that there is also a danger in this model. Where we know a fully integrated service that includes residential provision is of benefit to service users, there is a fear that where the budget for residential provision sits with the PBR provider, there may not be good engagement, and there may not be good, comprehensive use of that provision. We now know that such provision can really help those who have the most complex needs, such as dual diagnosis, and those who have entrenched offender behaviour and who will really benefit from a residential part of the whole pathway of care. Our experience so far in West Kent is that we have had one referral from the new PBR provider, and we would expect far, far more than that. That is the same story, I understand, as other residential providers in the seven other national pilot areas.
In conclusion, I think that there is huge opportunity, with the new evidence and research that we have, around what works for recovery. There is an opportunity to transform lives-the lives of individuals, families and communities-but at the moment I am not at all convinced that a payment by results commissioning model is the way to go. I think there is a danger that we may hit a target but miss the point.
Keith Vaz: Thank you very much. Are there any questions to any of the panellists so far? May I just start with the Committee?
Q6 Nicola Blackwood: One of the major concerns that has been raised with the Committee over treatment options and payment by results is the gaps between different areas of treatment, and between prisons and the community. I wondered whether the payment by results system takes that into account. I do not know whether that is perhaps one for Nicola Singleton, who has been doing the research.
Keith Vaz: I am sorry, this is like a very large dining table in a stately home. This is Parliament, so you don’t expect things to be perfect, and I apologise.
Nicola Singleton: One of the outcomes for payment by results is an offending outcome. In theory, the payment by results model could incorporate it. There are other payment by results in the offending area, and one of the additional complexities is how these all marry together. At the moment, what they have done is to have them in different geographical areas so they do not overlap, but there isn’t a coherent model for making these things fit together.
Q7 Nicola Blackwood: So although it is recognised that there is a problem of people falling through the gaps at that point, there is, as far as we can see, no mechanism to try to improve that within the payment by results system.
Nicola Singleton: The Peterborough payment by results is looking at that period of leaving prison, so there are payment by results pilots, but there are lots of them. Some areas may be looking at payment by results for recovery, but they are all very different. Basically, they are focusing mainly on the community treatment, but people come in and out, so they will be picking up people coming out of prison and they are considering how they do that. That is not ignored, but it is part of the additional complexity.
Q8 Dr Huppert: One of the live issues that we have had a lot of comment on-I think it was an issue in Portugal as well-was about what the aim ought to be. To what extent should the aim be complete abstinence, and to what extent should it be to move people down the road from acquiring drugs on the street towards either injection or methadone maintenance, and then towards abstinence? How realistic do you think it is to have a drive just towards abstinence? Will that result in people being parked as too hard to treat and hence not financially worth looking at, and being left on the streets with street drugs?
Nicola Singleton: To be fair, the outcomes included in the payment by results recovery include interim payments to try to recognise that for some people, it will be a long time before they achieve the abstinence outcome. The problem is, how do you know what weight to put on different ones? People move through at different times. If you give a high weight to the interim outcomes, you do not incentivise the long-term outcome that you are hoping to achieve. If you do it the other way round, the reverse applies. If there had been a single outcome that was just abstinence, it would probably have resulted in a lot of cherry-picking. The question, "What have you achieved by introducing the interim outcomes?" is something that, as a provider, you take a punt on and hope that, randomly, it will work out in your favour.
Angela Painter: In my experience, there definitely is not one size that fits all. We need to find some way of looking at individualised care, and we must find a way to recognise stepped change. We are offering people tools to ensure the sustaining of recovery, and we must have a way to measure that.
Q9 Bridget Phillipson: I have a question for Alex Stevens; sorry I can’t see you from down here, Alex. I have a couple of questions arising from your presentation.
The Committee has focused a lot on different ways of regulating drugs or otherwise. What I found quite interesting was what you talked about regarding the correlation between drug use and welfare policy, and how that links to decriminalisation and the other different approaches. Decriminalisation would not in itself address the underlying reasons why people begin using drugs. Looking at the different approaches in Portugal and Sweden, could you explain a little more about the reasons for the reduction in amphetamine use in Sweden? You said that restrictive policies did not give rise to that reduction, but I wonder what the reasons might have been.
Could you also comment more on Portugal? I found that some of the evidence you presented was a little mixed, in terms of the positive outcomes; I had expected to see slightly more positive outcomes from the Portuguese approach. I felt that the evidence was perhaps a little mixed. Will you comment on that?
Dr Stevens: On the first issue, it is absolutely right to focus on the underlying reasons of why people get into drug use and-perhaps even more so-why people get into problems with their drug use when most people who take drugs do not get into problems. A lot of that is about what other sociologists would call social dislocation-the fact that people do not have pathways to a meaningful existence, where they can create lives that are prosperous, wealthy and satisfying for them without getting into a problematic pattern of drug use. So there would be a mechanism, for example, whereby welfare gives people an opportunity to create those lives, because it gives them a platform on which they can base themselves when they are looking to create those lives. Imprisonment does the opposite. Imprisoning people takes them away from those opportunities. It reinforces their exclusion and deepens their stigmatisation.
One graph that I could show here is this one, which shows that there is not only a correlation between more generous welfare and lower drug problems, but a correlation between more imprisonment and higher drug problems. So there is some suggestion from the criminological literature that welfare and imprisonment operate in opposite directions, in terms of reducing the drug problem and other social problems.
If we extend that analysis to Sweden, it becomes speculative, because unfortunately, people were not doing research in the 1950s and 1960s, when amphetamine use was reducing in Sweden. You can see Sweden as a country that emerged from an extremely traumatic time in the second world war, when there were very high rates of amphetamine availability, partly due to the presence of armed forces that were provided with amphetamines. It became, over the post-war period, a very successful liberal democracy with a very generous welfare state, which has been very successful at integrating the aspirations of all its citizens. One might be able to link that to the reduction in drug use, but that would be very speculative.
Regarding Portugal, this slide shows the conclusion from the most recent article that we published, in which we weighed the two competing stories against each other-the narrative of success and of disastrous failure. While there has been selective use of the evidence on both sides to create a clear and unambiguous position, we think that the evidence is more nuanced, but generally positive, in that a reduction in HIV and death is an extremely positive outcome from a policy. The policy does not appear to have increased the levels of drug use to the levels that its opponents said it would. It has achieved the Portuguese Government’s aim, which was to bring people back from the margins of society into institutions where the state can support them into productive and meaningful lives. Our analysis is that the Portuguese story of decriminalisation, allied with welfare reform and expanded health care, is one of success.
Q10 Chair: Thank you, Professor Stevens. Can we now move on to our next panel-Professor McKeganey, Jan Palmer, Gary Monaghan and Mark Johnson? I want to start by opening this up to the audience. When you speak, it would be great if you could make your points as succinctly as possible and put questions to the panellists; that would be very helpful, as that is why they are sitting there. In order to get down everyone’s evidence, we need to know who you are. We are very keen to hear something new, rather than something that is being repeated. Apart from the Moroccan delegation, who are French speakers, is there anybody here who speaks fluent French?
Dr Stevens: Yes.
Chair: Apart from our panellists. Okay, that’s fine. I was just checking. Let us see if there is anyone from the audience who would like to say something. If you could say who you are and make your points within 60 seconds, that would be terrific.
Q11 Dr Eliot Ross Albers: I am the executive director at the International Network of People who Use Drugs. My question is really about PBR. It seems that PBR, and the recovery agenda generally, is disparaging methadone and putting it in an extremely negative light. I have myself been maintained for the last seven years on morphine. I do not see how good maintenance fits into the PBR framework. I really worry that people are going to be discouraged and not allowed to remain on maintenance when it works successfully for so many. Many of us do not wish to be put through recovery or abstinence programmes. We are quite happy with maintenance. I am worried that it is really not going to be delivered and will be discouraged. That is my point. It is not really a question.
Chair: Very helpful. We will park that, note it, and someone from the panel will come back and talk to you about that in a second.
Q12 Mat Southwell: I am an ex-NHS general manager. I was one of the people involved in East London responding to HIV. I now work in international development, taking the lessons of the now neglected British model out to the global environment. I also sit on the board of the United Nations AIDS programme as a civil society representative. We have recently been hearing from the Global Commission on HIV and the Law, which has really highlighted that when you criminalise and increase stigma and discrimination against the key populations affected by HIV-sex workers, gay men, drug users, and transgender people-you see an absolute increase in human rights abuses, and also a devastating impact on the response to HIV and on treatment uptake.
One of the things that we are increasingly doing-Europe and South America are leaders in this area-is starting to question how we can justify a drug control policy that drives up human rights abuses, contradicts the founding principles of the United Nations, and conflicts with the very programmes being run by UNAIDS. We are really starting to struggle with this. In this country, we would be horrified at abuses conducted against gay men, against women, and against transgender people, but we seem to not take the same approach when thinking about sex workers and drug users. The challenge in society, as the Olympics highlighted really well, is that we cannot leave people behind. We have to have a policy that is inclusive and does not just work to dogma, as the recovery model does, but recognises that drug use is highly complex and requires a range of different interventions. My question to the panel is: how can we justify human rights abuses against people like me who choose to use drugs?
Chair: We will come back to answering-at least I won’t, but the panel will-those questions very shortly. May I recognise Caroline Lucas, MP from Brighton, who hosted the Committee on a recent visit to Brighton?
Q13 Caroline Lucas: Thank you very much. Congratulations on an excellent session. I am not normally a fan of cost-benefit analysis, because there are lots of flaws in it, but I wanted to ask whether there has ever been a proper, rigorous, economic impact assessment or cost-benefit analysis of different approaches to treating drugs. If some of the other arguments might not be persuasive, I believe an economic argument would show that, were you to treat drug addiction as a health issue rather than a criminal one, not only would there be many of the benefits that have already been spoken about today, but it would, I suspect, also be an awful lot cheaper. At a time when budgets are under pressure around the world, not just in Britain, I wonder whether that might be a persuasive part of the armoury to try to persuade Governments to move a little more progressively on this.
Q14 Dr Deborah Judge: I am a child and adolescent psychiatrist working in Bristol with young people with problems with addiction. My question is partly for Mark Johnson and Dr Alex Stevens, and it is about their thoughts on these complex trajectories that children are growing up with in this country, which lead into the end-stage of addictions. A point was raised earlier about the Colombian policy. Including social policy, education and approaches to children at a much, much earlier stage in the process is important, because the young people that I see do not need locking up for their addiction problems. In the UK, we lock up more young people than any other European country. Where are the solutions? I certainly have my own ideas about those solutions, but I want to hear from Mark and Alex Stevens.
Chair: Thank you. Can we take one more, and then we will move on?
Sheila Bird: I am from the Medical Research Council’s biostatistics unit. My question is about PBR and the fact that there is no single protocol. Each of the pilot sites has its own definition of outcomes and tariffs, and the Department of Health is accordingly unable to produce or publicise the protocol by which payment by results will be evaluated. Can the panel say how they suggest the evaluation might proceed, when, in England and Wales, we do not count the dead properly? We do not know about drugs-related deaths until the coroner’s inquest is completed, and the waiting time for completion is at least six months. These pilot studies are short-term, and they will not know authoritatively which of their clients has even died.
Chair: Thank you very much.
Q15 Derek Williamson: I am from Cannabis Law Reform. At the beginning of this meeting you described the effect of drugs in somewhat dark tones, talking about the harm that drugs are causing to society. Are we not in danger of confusing the effects of drugs and the effects of drug law policy and prohibition? Is it not in fact true that the vast majority of drug use is totally non-problematic?
Q16 Peter Reynolds: I am also from Cannabis Law Reform and I am also the prospective parliamentary candidate in the Corby by-election. The point that my colleague Derek has just made is crucial. Prohibition always causes more harm than it prevents. Much of the discussion here, with respect to General León and people in the drugs support industry, is predicated on the idea of prohibition and the idea that it is something we must clamp down on. This process of clamping down is causing more harm. It is deeply depressing to hear the talk about the drug trade moving into terrorism. The reason the drug trade is moving into terrorism is because of the money involved. When you clamp down on something, the price goes up. When the price goes up criminals get involved. If you clamp down on it harder, the criminals become more violent. You clamp down on it harder, the price goes up again. It is an endless circle of destruction.
Chair: I hope I don’t have to read out the list of all the other candidates in Corby in order to give them a fair hearing. I think we will take a final contribution and then we will come to the audience afterwards.
Q17 Huseyin Djemil: I am a freelance consultant in the drug and alcohol field. I have worked across treatment with individual charities, individual people or whole treatment systems. I have also worked with law enforcement and helped police forces to work better in terms of their ability to reduce supply into their area. I am an ex-criminal and also an ex-drug user in recovery. I was formerly the London area drug co-ordinator for all the London prisons and I have been in the field since 1986. Currently, I am seeing a gap within the Committee. I have followed the Committee and helped several people with their evidence but I have not heard much talk of commissioning.
An MP talked about a choice between abstinence and harm reduction. All of this policy talk has to be translated on the ground. What I see is a real gap in terms of commissioners’ skills and commissioners’ knowledge and their ability to translate what they believe the national policy to be in their locality. As a result we are getting 31 different flavours of drug policy locally. As someone who works in that commissioning space, I am often called in, whether it is to drug action teams or to service providers seeking to meet contractual targets, to clean up the mess of that wrong interpretation. So some comment on where commissioning fits is needed because that is where we translate the good practice and the high ideals into reality for an individual whose behaviour we are seeking to influence.
Speakers: Professor Neil Mckeganey, Founding Director, Centre for Drugs Misuse Research, Jan Palmer, retired author and lecturer on substance misuse, Gary Monaghan, Governor, HMP Pentonville, and Mark Johnson, User Voice, author, Visiting Associate of University of Durham and Probation Trust Board Member.
Q18 Chair: That is very helpful. Let us move on now to the second panel: Professor McKeganey is the head of drug research at Glasgow University. I think I pronounced your name wrongly. I don’t speak Scottish.
Professor McKeganey: It is close enough.
Q19 Chair: Thank you. You are very polite.
Jan Palmer is an independent clinical substance misuse adviser. Gary Monaghan is the governor of Pentonville prison and Mark Johnson is the founder of User Voice. I want to start with a question to the governor of Pentonville. The Committee visited two prisons, yours and Brixton. Shortly after we visited your prison there was a breakout. I hope it was not connected in any way to the visit of the Home Affairs Committee and that you caught the person who escaped. What surprised us-I don’t know why we were surprised, but we were-was the large amount of drugs that had ended up in prisons. We thought prison was an opportunity to get people off drugs but people went into prison with no association with drugs and came out having become addicted while inside. This is a big failure of the system. Why do you think this happening?
Gary Monaghan: I will talk about my own establishment. It is 170 years old and so I will start off with the physical factors within prisons. When it was built it was surrounded by fields. Substance misuse was not such a big issue. In an urban environment it is now totally surrounded by buildings. It is very difficult to stop supply into the jail because associates of prisoners inside constantly try to throw packages of drugs into the establishment. We consistently have to battle with preventing substances from coming into the jail. There is also the fact that people secrete items about themselves when they come in from court. They will bring them in when they get arrested by the police. They hold them on themselves, which we cannot get to. They bring drugs in themselves.
When the prison was built, visitors did not have physical contact with prisoners. We now have domestic, social and family visits. It is part of our trying to maintain their human rights, and part of our rehabilitation strategy. Unfortunately, sometimes some of those visitors will also bring drugs into the establishment. Sometimes we have members of staff who will bring substances into the jail as well. It is a battle for us, because the economy in a prison means that drugs in prison are worth several times the value out on the street. The more successful we are in terms of reducing the supply into the establishment, the higher the price of drugs.
In the past-I think things have changed quite dramatically now-we had very limited substance misuse programmes. Pentonville has the biggest substance misuse programme in the country. As a result of that, we are helping to stop and deter people from starting to abuse substances while in custody, so I think the trend is being rapidly reversed over time. I am not going to say it does not happen, but because we have developed such an extensive approach towards substance misuse in custody, I think that the likelihood of somebody coming in without a habit already is quite reduced. We have support and drug-free wings-
Q20 Chair: It really is very odd that the one place you do not expect to see drugs is in our prisons. If you are going to break the cycle, is that not the best place to do it?
Gary Monaghan: It depends on the individual concerned. For some individuals it is not as straightforward as saying, "Put them in prison. That is the best place for them and that will resolve their issues." We have a high level of dual diagnosis-for example, substance misuse and mental health problems-so it becomes more complex. Prison might not be the best place to help such individuals. We have other individuals who may be creating a lot of damage in the community because of substance misuse, and maybe the best place for them is prison. It is a difficult and complex area. How we will deal with an individual very much depends on the individual we see in front of us.
Q21 Dr Huppert: I am interested in trying to get a handle on evidence of what happens. Some research has been done looking at what happens to people when they are exiting prison. I think the research is a few years old now. I say that with some nervousness because I know that the person who did the research is in the audience. It showed a large number of deaths within two weeks of release of people who have taken heroin. Professor, I will not try to pronounce your name, given that Keith has already gone through that process. What should be done to reduce that surplus death load on exit? I think the figure at the time was that one in 200 people who have ever injected heroin die within two weeks of leaving prison.
Professor McKeganey: There is no question but that if we do not have the best treatment available within our prisons, we have no prospect of dealing with our drug problem. We will witness major problems for the individuals. As they leave prison they will experience heightened risk of death. We will see our prisons gradually overtaken by drug problems and we will not address the drug problem in the wider society. I think the figures on the elevated risk of mortality on leaving prison have led to a reassessment of the nature of the treatment that should be available within prisons. If we get that right-if we have treatment that is oriented towards recovery, which ensures that prisoners get high quality treatment-we will do our best to reduce that level of mortality.
But we should make no mistake here. At the point at which an individual leaves prison, if they resume the previous pattern of drug use, they face an elevated risk of death-unquestionably. That arises because of the highly risky nature of the activity that they engage in. We must commit to ensuring that treatment is available in prison and does the most we can to reduce that risk, but does not take responsibility on behalf of the individual, where they go on to resume that pattern of highly risky drug use after leaving prison. We have clearer guidance now on how to ensure that the treatments available in prison are the best that they can be. That is a major step forward. We should not assume that treatment delivered in prison is an easy option. It is an environment that needs to balance issues of security with treatment and recovery. Those things do not necessarily sit easily alongside each other, but that is the challenge that we face.
I also think we need to recognise that it is important that methadone is made available to prisoners, and that it is contributing to their recovery, but we should not be in any doubt that the drug problem within prison is not answerable by the provision of the single treatment methadone. We are now seeing the development of new legal high drugs, new psychoactive substances, which the Chair drew attention to. They in turn will pose a massive challenge to prisons as they start to appear in the prison environment. Our responsibility is to ensure that we have the best available treatment in prison. That is not what we have been doing up until now, but it is a commitment that is increasingly now recognised.
Q22 Dr Huppert: You draw together the treatment within prison. I did not hear anything about the link between inside and outside. I worry that there will be a silo of one set of processes in prison and then a complete disconnect to what happens outside, with people falling between that crack. It happens for released prisoners in a range of areas such as benefit payments and other things.
Professor McKeganey: I apologise in that regard. You are right that we have to get the relationship between prison, the wider community and the family to work to optimum effect. We have to ensure that where an individual leaves prison, having benefited from the treatment services available in prison, that the progress they have made is not diminished, diluted and dissolved on exit from prison. That requires a very close working relationship between treatment services within prison and outside. That is more achievable now, I think, where you have the same treatment services working within prison as working in the community. We also need to draw upon the family and the wider community to ensure that those influences that can encourage the resumption of patterns of drug use on exit from prison are themselves addressed. Treatment can only do so much, even when it is well integrated between prison and the community.
Q23 Bridget Phillipson: I have a couple of questions on treatment that might be best addressed by Jan Palmer or Mark Johnson. First, I would like your views on the role of residential rehab. My experience in the north-east is that residential rehab is hard to access. There has been a move towards home detoxing and treatment in the community. That, of course, has its place but often appears to be a short intervention that leads to not much afterwards. People will often return to the habits they had before because they have not received the right level of support. I appreciate that residential rehab may not be entirely the answer, either.
Secondly, I would like to hear your views on methadone maintenance programmes. The debate appears to have become quite polarised between those who think abstinence-based policies are the only approach and those who feel the Government are going too far in the other direction. I accept that moving people from methadone is often appropriate, partly because my experience prior to becoming an MP is that sometimes people end up parked on methadone for long periods. That might be right for some people, but others do not seem to be given the option whether they want to remain on methadone. They are just left, sometimes for five, six or seven years and the treatment is not properly reviewed. It is a question of reviewing people receiving methadone, not just the application of the policy.
Mark Johnson: A quarter of the NTA’s clients were on state-sponsored methadone for a four-year period. More than half were on it for two years, which is called "parking people", without the option of moving on. As for how that relates to prison, given that drugs are illegal in this country and a person’s crimes were attributed to problematic drug use, why does that person go to prison and have access to more drugs? I have always found that fascinating.
In 2009, the NTA spent £4 million on auto-dispensing machines of methadone in prisons. In my column in The Guardian, I called it the "saddest queue that I have ever seen", when I described a group of 100 prisoners at the top of a landing shuffling to get to the dispensary. Where did the supply of methadone in prison come from? In 2006, a group of prisoners took the Government or the Prison Service-I am not sure which, because it is difficult to get information on the issue-to the Court of Human Rights about the right to treatment. It was said that their human rights were breached because they could not have access to the same treatment inside prison.
There have been no recorded deaths from opiate withdrawal. [Interruption.] That is my information that I have collected for more than 12 years. It is probably worth having an inquiry into it. In 2011, 596 deaths were related to heroin and morphine use, but 486 deaths were the result of methadone. Returning to the use of methadone in prisons and retoxification, Professor McKegancy talked about treatment. I would like that defined. What is "treatment"? I have met people who had been on an abstinence-based programme and had been retoxed before release, too. On release, some have not been connected to an outside GP, in which case there is an inevitable risk of their resuming their previous pattern of behaviour.
Jan Palmer: I should clarify my role. Until March this year, I was the national clinical policy lead for substance misuse at the Department of Health. I had been working on and developing services in women’s prisons since 1997, when I led the development of what was then the first ever detox service, but which gradually became more robust clinical substance misuse treatment service for women. That eventually underpinned the development of the whole integrated drug treatment system in prisons.
I am not therefore really in a position to answer the question about rehab, because my whole experience has been working with prisons and the criminal justice system. However, I can comment on methadone maintenance in prisons, and I am able to dispel any rumour about the automated dispensing of methadone in prisons. I can also comment on re-induction, which is the formal name for what has just been referred to as "retox". I am not quite sure what I am required to say, but I am happy to deal with such points.
The word "recovery" is being interpreted as abstinence, and we are desperately trying to make sure that that interpretation is not automatic in prisons, because of the risks of post-release death. Methadone maintenance and re-induction are both protected factors in preventing post-release overdose. People who have engaged on an abstinence-based programme in prison might well find it impossible to maintain that position at the point of release. In the past, we have been criticised by coroners for forcing people into abstinence in prison when people have died subsequently. Re-induction, which is permitted by the national guidelines in this country, not just for prisons, allows us to enable people who really cannot maintain that abstinence at the time of release to restabilise on to a dose of methadone, usually, but it could be buprenorphine, to prevent their death upon release. We would also automatically try to ensure that those people are then linked up with treatment services at the time of release.
Ongoing treatment at the point of release from prison is a critical factor in ensuring that people not only engage with treatment, but, frankly, don’t just die at the point of release. Prison can, as Gary mentioned, be an excellent opportunity for people to stabilise and engage in treatment and to look at their options to work towards abstinence. We never lose sight of that fact. Prison may not be the right place for some of them to do that. There are negative effects of being in prison, as you can imagine, that make it harder and it is not necessarily the right time. There should not be a rush to get people to give up prescribed treatment when they come into prison. They should be able to work towards that, the same as they would in the community and over several years if that is necessary. We need to ensure that treatment services in prisons work in a similar way to the community, without people having time placed on their treatment options.
Mark Johnson: I strongly disagree with what has just been said. Coming back to the residential drug treatment-on average a quarter of those on methadone are parked for four years or more and half for two years-one year’s supply of methadone, without all of the outside services, would pay for four to five weeks of residential drug treatment. So if you take that average of four years, you’ve got a really good treatment package for somebody. I do believe it is an emergency. I don’t believe that people should be parked on methadone. Whether it is a quick or a long, slow death through the green liquid, I think that we should make an absolute commitment to get people off if they want it. A large proportion of the people I met, who are parked in prison and on methadone in the community, want to come off.
Q24 Chair: That is very helpful. Now, everyone is being very nice to each other and we would like them not to be. The way you make policy is through friction, I understand. So could we first see people who have not spoken yet who would like either to put a question or to make a brief statement?
Darryl Bickler: I am from the Drug Equality Alliance. I am a solicitor with former experience in human rights and criminal law. I am actually quite surprised that we have not yet at any juncture throughout this entire inquiry looked at the law and the way it has been administered. We seem to have started off with an artificial divide that is accepted as normal. When Professor Stevens talks about a drug-free world, we know he does not really mean that. They don’t mean that in Switzerland. They mean a certain type of drug-free world. We have this artificial divide so firmly implanted in our psyche that somehow the problem is about people with methadone and cannabis and is not about the vast majority of people who are suffering problems from drugs misuse, which is prescription drugs, as you mentioned in your introduction and the so-called legal drugs of alcohol and tobacco. We seem to be shying away from looking at probably 90% of the entire drug misuse problem. We are avoiding that quite conveniently because we are not picking up on what the Home Office has set up. The Home Office has set up an artificial divide, which is not provided for within the Misuse of Drugs Act. It has set up an artificial divide between people who are given a free pass. They are allowed to produce dangerous drugs and sell them, but they’re okay because they are making supposedly legal drugs-although you won’t find that in law. Then you find people who have no human rights whatsoever. They could be the most peaceful self-medicating people who are using a herb at home and yet they could go to prison for 14 years, because they are using so-called illegal drugs, which means that there is no division or differentiation being made between peaceful use and misuse of drugs that is giving rise to social problems. The Committee is supporting that position, and I am angry about it.
At the beginning of this introduction, you said that you are looking at illicit drugs-that is what you said, Mr Vaz. There is no such thing as illicit drugs. They do not exist. It is as simple as that. It is not that we understand what they are by "controlled drugs"-that is the legal term, and I would be obliged if you would use the correct legal terminology for this inquiry. I am not being technical; I am just being exact, because it is important. There is a huge difference between talking about illicit drugs, which do not exist, and controlled drugs, because it is people who are supposed to be controlled with respect to outcomes. Those are antisocial outcomes caused by drug misuse. Those people are supposed to be regulated rigorously, whereas people who cause no problems should not even be within the purview of these Acts, and yet they are. Question after question is asked about whether we should decriminalise some drugs and legalise some drugs, but we cannot do that. It is impossible.
Chair: That is very helpful indeed. I think Sarah has not spoken, but, before you speak, may I also welcome Diana Johnson, who is a shadow Minister in the Home Office? Have I missed any other MPs who have slipped in apart from Caroline and Diana? James Clappison, who was here briefly, but who has gone, is also a member of the Select Committee.
Q25 Sarah Graham: I am director of Sarah Graham Solutions and a member of the Advisory Council on the Misuse of Drugs, although I am speaking in an individual capacity. Thank you for today. It has been very interesting.
I am standing here today clean and sober of all mind-altering substances for 10 years, and I am able to be here, in recovery, because I was able privately to afford eight months of residential rehab. Rehab does work. I am absolutely appalled by what Jan was just saying because that thinking leads to, for example, my colleague here, Dr Deborah Judge, being asked to retox a 17-year-old going back into the community from a detention centre, because we do not have the adequate residential rehab facilities in this country. We do not have a single residential rehab facility in this country for our young people. Instead, we demonise our young people. We call them hoodie yobs. We don’t diagnose them, and we don’t treat them. The NTA is happy to put those young people into care homes-and we have recently heard in the media what those care homes are actually like: young people are sent away far from their communities, given no actual support, and abused by paedophiles-and also into the criminal justice system. We happily spend in excess of £4,000 a week putting a young person in a criminal justice system environment, but we don’t adequately treat them. Dr Judge has a fantastic model for treating those young people. There are many people in this country who think that we should have residential rehab, and I am one of them.
If you are interested in this subject, please google "Teen Rehab? Yes, Yes, Yes!" and you will see a short film about this subject. We have to change this policy. It is outrageous. If we invest in treating our young people, we can arrest this illness and we can save our society so much money in terms of welfare, criminal justice, health care costs, and the costs to the individuals and their families.
Q26 April Wareham: I am from the National Users’ Network. We are made up primarily of current drug users, people who define themselves as being ex-drug users, and people who are using prescription drugs only, whether that be methadone or other forms of opioid substitution therapy.
When I speak to my members, I hear people talk about the fight that they had to get adequate doses of maintenance. I hear people talk about the relief it was when they got the medication that they felt enabled them to live their lives. It has enabled my members to attend university, to bring up children, to hold down jobs and to be productive, useful, happy members of society. I know that long-term opioid substitution therapy is not for everyone, and I will never say to somebody, "You have to have it if you want to give up." For the majority of my members, however, it has been a life saver and a lifeline.
Chair: Very helpful, thank you. Gosh, there is a forest of hands. I assume nobody has spoken before who is putting up their hands. We will come back. We will have Baroness Meacher, a fellow parliamentarian, next, and then we will go to the back row.
Q27 Molly Meacher: I am the chair of the all-party parliamentary group on drug policy reform, and I thought I should just ask the Select Committee if they will try to take account of the new so-called legal highs. We have just done an inquiry into those, and we have been very struck by the evidence we have had from the regulatory authorities, ACPO and all sorts of other major organisations responsible for these and other related issues. They have said that the current legal framework simply cannot and will not be able to deal with these new psychoactive substances. It is absolutely essential, it seems to me, that the Committee raise that point and make it very clear, really seeking a completely new approach to dealing with drugs. We cannot go on the way we have gone on now for 50 years. The solutions are complex, but they have to be very different from what we have got.
Q28 Steve Brinksman: I am a GP in Birmingham and I am the clinical director of Substance Misuse Management in General Practice, which is a charity organisation designed to help our members be aware of the best evidence around all substance misuse, legal and illegal, prescription, alcohol-everything. I come to lots of these events and I wonder why everybody insists on painting themselves into ideological corners through polemic. It is about helping the people here who have the issues. This is not a case of, "It’s abstinence or it’s methadone." There is a spectrum. You take people in dire need, you work with them as an individual and you help them find the solution that is for them. I abhor the idea of anybody who has been left on methadone who wants to move on from that, but equally I abhor the idea of anybody who is forced to move on from that when they feel they have got their life in a reasonable sense of order. That involves ongoing review with people, but it is a spectrum.
Professor McKegany was recently part of the Medications in Recovery project, which produces a good report showing how we can use some of the tools that we have available to help move people on. Mr Vaz, you talked about not having consensus, but consensus is what we need in this area. If we can stop going on about our own little bit of the world and work together, we can produce something for the person who matters-the patient, the user, the client or whatever you want to call them.
Chair: Very helpful. Don’t worry if you are not called, because we are having break-outs where you can speak for slightly longer than you can in the plenary session. I just want a word from the panel before we conclude, and our colleagues from Morocco are going to say a couple of words at the end. Could we have the gentleman who just stood up? When you have finished, please hand the microphone to the gentleman who has got his hand up immediately behind you.
Q29 David Hannay: I am a retired general practitioner who worked for 16 years in the centre of Glasgow, two years in rural practice, 10 years in Sheffield and then back into rural practice. During the 10 years in a rural practice, heroin addiction became rife; it was not there before. Last year, there were twice as many drug-related deaths in that rural area as there were the year before. The local prison has well over half its inmates there for drug-related offences. Prison is not the right place to put people who are on drugs, because the idea that they will get adequate treatment there is, in many places, a bad joke. We must stop criminalising possession. One very brief analogy: people on heroin are highly addicted and they require the drug-they need it. It is a bit like diabetes. You would not prosecute people for having insulin in their possession, but you would quite rightly prosecute people who tried to sell insulin outside the NHS.
Chair: You chose the right illness, because I am a diabetic myself. Did you know that before you said that? You didn’t. Very good.
Sanj Chowdhary: I am from Normal. I am a drug user. I do not feel that I should be persecuted for my drug use. I do not harm anyone else in society. My question is quite simple: is all use misuse? If not, why should I be persecuted for my choice of substance over someone who drinks alcohol?
Q30 Chair: Since you have raised it-I am very interested in this-what drug do you use and why do you use it?
Sanj Chowdhary: I am currently a cannabis user. I use it for medicinal and recreational purposes. I have used all sorts of other substances in the past-cocaine, heroine, speed, MDMA; all sorts, really.
With the drugs on the black market, once the gateway has been opened with cannabis-it does not lead to harder drugs, but it opens a doorway into an illicit black market-you are offered all sorts. To be honest, I thought that the benefits I got from the illicit substances, in terms of enjoyment and the reduced negative effects-I did not get a hangover, as I would from alcohol-were better.
Chair: Thank you. Very helpful. If the gentleman at the back can be equally brief? I want to go to the panel, and then I want to take a quick word from the Moroccans.
Q31 Greg de Heodt: I am Greg from the United Kingdom cannabis social clubs. We are part of a European movement that wants to implement a bit more regulation and control over the cannabis market, rather than leaving it to the unscrupulous gangs that are currently growing and selling it at ridiculous prices, with it being contaminated with all sorts of problems, to anyone without any ID. Currently you can be 12 years old, have a £20 note, give it to a dealer, and they will give you a bag of weed, or anything, really. We want to stop that kind of market. We want to have a safer market for people who already consume cannabis, so that they can get it in a regulated way and know what potency it is and the strengths that are best for them. If they are a medicinal user, that would be much better than getting it from the black market, where it is contaminated and could cause more health problems. I wonder why the Government are currently spending £500 million to police people who are consuming and growing cannabis.
Q32 Chair: Very helpful, thank you. I am going to stop the audience for the moment. Are there any burning issues that any of you want to pick up, very briefly? We are on time again, which I am pleased about. Is there anything that you want to pick up on? If not, that is not a problem. Is there anything that has come up in what you have heard that you want to respond to?
Jan Palmer: My two GP colleagues, perhaps not surprisingly, and I would like again to endorse the fact that we would not, in a prison environment, support just parking anyone on methadone, but nor would we wish to rush people towards abstinence. The diabetic analogy also demonstrates that. I think that is a middle-of-the-road, sensible approach to treating drug users who have other complex needs, because they are offenders as well. That is exactly the way we see it within prisons.
Mark Johnson: My burning issue is about metrics. We do not have a robust enough set of metrics to measure effective outcomes for people. I refer you to the current situation over residential rehabilitation and how the figures have shown that to be unsuccessful in getting people into long-term recovery. It is about the metrics failure rather than the treatment failure. It is measured on a three-month cycle of treatment, but three months is the highest rate of recidivism for an offender, and it is the highest rate of relapse for a drug addict. What it does not measure, however, is that it takes two or three attempts at getting into the recovery journey for it to be effective. It also does not measure the impact of a successfully rehabilitated offender or drug addict in his community and that is where metrics really need to go. It is about the effect on peer groups and the different environments that that person comes from.
Q33 Alun Michael: The three GPs have referred to the importance of review and movement and reflecting the wishes of the individual patient, and that is fine, but how do you ensure that you get that professionalism of review? It is not always present in the health service and that is not just related to harmful drugs.
Chair: Did you want an answer?
Alun Michael: Yes.
Chair: From whom do you want the answer?
Alun Michael: The GPs are recommending good practice, but how do you guarantee good practice when you are offering it as an alternative to other policies?
Chair: I have forgotten which of the GPs have spoken.
Dr Brinksman: I agree that there are issues in any area of medicine with variability. One of the things that we have got coming in is revalidation, which is looking at people’s ongoing training. A big issue is that working with substance misuse and even alcohol-using patients is not a part of the core GP contract. Actually, that and putting it in there and using things like QOF to support that is the right way to drive the standards up. Setting minimum standards and getting people to adhere to them is what we need to do. At the moment, there is no pressure on many of my colleagues to do that.
Q34 Chair: Finally, we are going to have a short speech from the Moroccan delegation that is here. It will be translated for us by the Moroccan embassy. Could you please welcome Mr Mekki el-Hankouri, a member of the House of Representatives at the Moroccan Parliament?
Speaker: Mr Mekki el-Hankouri, Member of the House of Representatives, Morocco.
Mr el-Hankouri:(Translation) Thank you, Mr Chairman. Ladies and gentlemen, members of the audience, first and foremost I thank the organisers and the British authorities for this important event and their warm welcome today, for which six members of the Moroccan Parliament and authorities are present.
Morocco is aware of the inherent dangers of cannabis production and its long-term negative effects on those who use it, and has adopted a comprehensive approach in the struggle against it. Significant progress has been made by the Moroccan authorities and there have been huge advances in the fight against this scourge. The main results have been confirmed and corroborated by both national and international statistics. Among the main results has been the eradication of more than 10,000 hectares of cannabis in the past two years. The cultivated area of cannabis has been reduced by more than 65%, having gone down from 134,000 hectares in 2003 to 47,500 hectares in 2011. These figures are not only the Moroccan figures; they have been corroborated by UN sources-the OECS and the ONDC.
Given its geographic position, Morocco constitutes a barrier to drug-trafficking routes. For this purpose, the Moroccan authorities have put in place a strategy against trafficking networks by reinforcing border crossings, whether they are maritime, land or air borders. This has led to significant results. In 2011, the Moroccan security services seized 119 tonnes of cannabis, and in the first five months of this year 42 tonnes of cannabis.
Morocco would also like to point out that, in the past few years, we have been confronted with cocaine drug-trafficking organisations, coming either from certain west African countries and transiting through Morocco, or from Latin America and destined for Europe but also returning to Morocco. This seriously complicates the work of the Government.
In parallel with this security strategy, Morocco has put in place a strategy to deal with drug users-"toxicomanes", as they are called. It is a social strategy, and different centres have been opened to treat those who are recovering. There is co-operation in attempts at drug eradication among countries that, like Morocco, are constantly fighting against the illicit use of all drugs. The co-operation that we have undertaken with different countries has led to different attempts, not only regional but also international, and to improving the capacity of services in this field, especially Moroccan services.
Finally, Morocco places particular importance on international co-operation, above all with neighbouring countries-Spain first and foremost, and the rest of Europe-to fight on all fronts. To that purpose we have, for example, signed many agreements on extradition with countries, but our co-operation with Latin America has become very important. We have also co-operated with countries that have decriminalised drugs, namely cannabis or hashish. Morocco is interested in putting forward an alternative scheme. Morocco has made many efforts and strides. We have had different policies, including large projects such as the national initiative for human development, which addresses issues such as crime and drug use.
Thank you very much for your help and time. We are counting on your help.
Q35 Chair: Thank you very much. That was very interesting. May we ask where the drugs come from-the cocaine that enters the country? How does it get to Morocco? We are interested in following it from Colombia.
Mr Abderrahim Habib: (Translation) First, thank you for that presentation. Analysts say that the cocaine comes from West Africa, and goes to Europe via Morocco. Last year and this year, another trend has been noted: cocaine from certain Latin American countries-
Q36 Chair: Is that Guinea-Bissau or Nigeria? You talked about West Africa.
Mr Abderrahim Habib: (Translation) In West Africa, the drugs come from Guinea-Bissau, Mali, and also commercial flights. Commercial flights are seen as a major problem as well.
Chair: Thank you all for participating in that first session. It was interesting to hear from the Moroccan delegation on what they are doing. We will now break up into workshops.
On resuming-
Q37 Dr Huppert: Thank you all very much. I hope you found the breakout sessions useful, and I hope we will now have a chance to hear summaries of those sessions. The group I chaired had a very interesting discussion, and it was hard to come to simple conclusions. I am looking forward to hearing the conclusions that have been drawn out. Can we start with a report from the group on whether drugs policy needs to be global, chaired by Nicola Blackwood? There will be a full transcript of what the rapporteurs report back to us, and this will be very helpful in our evidence. Notes were taken of everything said, but they won’t necessarily be verbatim. Molly, could you briefly summarise what was said in your group?
Baroness Meacher: Yes, this is always the most difficult job, because people say about a thousand things and one is allowed to say about five. The key issue for us was that, of course, we need a global drug policy, but we know that global drug policy depends on the UN conventions. In our view, it will take many decades to change those conventions, and we cannot wait.
Secondly, if you are going to achieve good policy, countries have to have the freedom to try new and different policies. I do not think anyone feels that the world has the answer. We need individual countries to have policies suited to their own specifics, and we need to evaluate them. We need evaluation, evaluation, evaluation, and then we might achieve the right answers.
People wanted me to talk about the inequalities between nations. Many African countries are becoming more and more involved in this, with a huge amount of corruption threatening the integrity of the state. We in the west need to support countries that are struggling to deal with this incredibly difficult problem.
We cannot control the supply of drugs across the world. That is impossible. Perhaps we can control 1% of the supply, or 20%. Different percentages are controlled in different parts of the world, but we will never control supply effectively. We have to control demand. That means looking at education and demand-focused policies, but not through criminalising young people because, again, you have the balloon effect: if you try to criminalise people for using cocaine, they will use some new psychoactive substance that is more dangerous and more unknown.
Those are some of the points that were raised, but I am certain that they are not all of them. We need new regulatory systems for controlling drugs. You cannot just have freedom of supply. Obviously, drugs need regulatory controls of one sort or another. We need to accept that there will always be considerable drug use across communities across the world. We cannot eliminate drugs.
Q38 Dr Huppert: Thank you very much. That was said in admirable time; you are clearly a practised parliamentarian.
We now move on to the second group: how do we determine the most effective methods of treating addicts? That group was chaired by Mark Reckless. You have about five minutes.
Mark Reckless: Thank you, Julian. I am extremely grateful to everyone who attended our group on treatment. I am not sure I am in a position to present conclusions from that group, let alone ones that everyone would agree with, but I shall try to identify some themes that emerged from our discussion.
First, we addressed these questions: what is the aim of treatment? What is recovery? Participants emphasised that that would depend on the patient. A successful result could take a great variety of forms, depending on the aims, objectives, personality and history of the particular patient. One participant stated that if we are talking about a health outcome, the objective has to be a happy, fulfilled life. The view of most in the group was that for at least some people, including those speaking for themselves, that might involve continued maintenance or use of some description. I was told that that might be opiate substitute therapy; it is not always methadone maintenance, and that was an important distinction to make. Describing people as being "parked" on methadone might be pejorative, although I think some people would emphasise that it is very important for the individual to have the choice of coming off drugs entirely, if that is their objective. As part of that, reintegrating people into society, whether through education, employment or social life, was also an important objective, and individuals who continue treatment or maintenance of some description could well fall into that category.
We also discussed the importance of residential rehabilitation. I understand that 10% of spending was on that, but 2% of users come off in that area, so it is clearly a more expensive and resource-intensive treatment. There was perhaps an association between residential rehabilitation and a focus on abstinence, which may or may not have come from the providers running the residential treatment centres, a number of whom I know came from a religious heritage. It was said that there was often a life-cycle, whereby a drug user would have treatment in the community, but would then come into residential treatment and potentially go back to community treatment. Therefore, it was not necessarily helpful to posit a binary distinction between residential and community treatment.
There was, however, a degree of agreement that residential treatment was important and should be there. In particular, if someone was not coming off drugs through community treatment and wished to have that residential opportunity, it was important to provide that. A number of participants were almost angry that there was no option for residential treatment for teenagers and adolescents-many of whom come from chaotic backgrounds and families-who were developing addictive behaviours, often with social issues as well as health issues. At least providing the option of residential treatment for some people in that category was something important that we should aim for to save the next generation.
Finally, we discussed payment by results. A wide spread of people in the room were concerned that payment by results would be very bureaucratic, from what we were seeing in some pilots, and that it would not promote the results that the Government were looking for. Although there may be some tension between the Government’s stated aim of abstinence and the views of some in the room, the payment by results model could not be expected to achieve the Government’s goal because of the way in which it was being implemented. Some hoped that there might be different local approaches, and people in each locality may know best about the circumstances there. None the less, there would be great complexity, in terms of the commissioning decisions and how that would link into the payment by results agenda and tie back or otherwise to the Government’s objective for their drug policy.
That is my attempt to bring forward a few themes that emerged from our discussion. Once again, I would very much like to thank everyone who participated.
Q39 Dr Huppert: Thank you very much, Mark. The next workshop was on the physical and ethical harms of drugs, and how we reduce demand. It was chaired by Alun Michael MP, who will summate it.
Alun Michael: I shall try to keep the focus on reducing demand, because it would be very easy for us to go over all the ground covered in each group and go nowhere. I have to say a great word of thanks to the members of the group; it was far more productive and informative than I had dared hope.
First, things came out about the need for reduction and prevention to be holistic and linked to the nature of the community and community development. It was said that starting with localised data and empowering communities to choose their priorities is the way to begin addressing the environment in which drug-taking can be a problem. It was suggested that programmes such as Communities That Care, in the US, and those run by Rowntree here have shown good results in public health terms.
Secondly, we should look at the comparison between the way we seek to reduce demand in relation to drugs and the way we seek to reduce demand in terms of tobacco and alcohol. You do not have to regard the legal status as being the same in order to look at the methodology of the approach. That is about education, media models-you don’t see people with a fag in their mouth on our television screens nowadays, not even the hard-bitten detectives-advertising, and so on.
Thirdly, with regard to perceived harm, it was suggested that we needed to be very careful coming in from the outside, particularly to groups and environments in which drug taking is accepted or part of the norm. We need to be inside, offering data and so on and understanding the environment in which things are happening-in other words, looking at the environment in which drugs are used. It was suggested that we are not doing enough in terms of the club environment. We need to be there in order to influence what is happening. How effective are we in the night-time environment?
A director of a rehabilitation centre gave us evidence of having asked people how and when they started, and having found that the starting point was very often bad self-image, came a lot earlier-at the age of 12 or 13-than is often expected, and had very direct links to poor education and local problems of all sorts, rather than drug taking being the only problem in the environment or peer group. The peer group was mentioned several times. There was talk of the use of mentoring and working with youngsters to understand the impact on them of their choices.
It was suggested that we do not sufficiently ask this question: why did you stop? The point was made that the British crime survey demonstrated a reduction in use, and therefore that is a reduction in demand. Cannabis use halved in the 16-to-24 age group, and there was a drop in heroin use. The point was made very strongly that we do not know why, because that question is not asked, and the research is not undertaken. We might be able to be informative if we understood why the trends are developing.
It was suggested that we often underestimate our young people. They want to know how things work. They respond better to being treated intelligently, being given information and being engaged with. Too often, however, schools are in denial. They may have a drugs policy, but they may also have drug taking and be in denial about that. The headline message there was: don’t patronise young people.
Finally, the point was made that the Home Office leads on drug policy, and the priority statement, which is comparatively recent, did not refer to education or prevention. Incidentally, there is a move in the same direction with the Home Office lead on alcohol. We are talking about a narrower approach that does not include public health and with educational and community-based understanding of the environment being lower down the order of priorities. It was also said that we are not very good at cross-Department working in the UK. As a former Minister, I can tell you that is bloody true. The suggestion was that we should learn a bit from France.
It was a fascinating discussion, raising quite a lot of practical issues about how we put drug policy in the context of wider social policy, rather than seeing it as a separate strand. I was pleased by the extent to which references to the peer group came in, because as a former youth worker, I have always felt that we grossly underestimate the impact of the peer group. It is very often far more influential than the parents on the decisions that young people make.
Q40 Dr Huppert: Thank you, Alun. The question considered by the last of our groups to report back was: what are the alternatives to prohibition? It was chaired by me, I should admit, but I wasn’t brave enough to try to present all the findings to you. Where is our rapporteur? You have about five minutes.
Dr Sue Pryce: Inevitably, with the title we had-what are the alternatives to prohibition?-our group attracted people who were already fairly convinced that prohibition was not the way we should continue, so we were already sold on the idea of some form of regulation and control, but the question was how that would come about. What are the alternatives to prohibition? Well, it was suggested by the group that there is a spectrum of alternatives, from regulation and control of some drugs to regulation and control, or legalisation and control, of all drugs. Obviously the level of support varied in those groups.
There was inevitably also a focus on cannabis. Many people felt that cannabis could be safely legalised and controlled, and they tended to shy away from our major problem drugs-perhaps not cannabis but heroin-and the impact of heroin and class-A drugs on families and users generally, and on society, in terms of crime and other issues.
All the alternatives seemed to have cost benefits. Decriminalisation step by step was favoured by some people, who felt that decriminalising different drugs at different times and evaluating the evidence that emerged would enable a better picture to be developed, because one of the key problems with the idea of going straight from prohibition to legalisation is how we would know what would happen. It is the unknown, and the question of whether there would be more users. Although some of the claimed evidence suggests that perhaps nothing, or very little, would change, that did not seem realistic to many people in our group. It seems likely that there would be an increase in use. Certainly, after prohibition of alcohol was removed in America, the immediate result was an increase in use, but it did eventually level out. There would be a period when a certain amount of increase in use would be inevitable.
Obviously a lot of the focus was on the benefits of some alternative to prohibition, such as more positive policing-the police would be able to divert their resources from the huge, costly drug-war prohibition enforcement to improving community relations. Money would also, of course, be diverted towards better treatment for problem drug users.
There were questions about whether drug legalisation would reduce crime. Part of our group felt it would reduce crime, but other people felt that that would not happen-that just as there are illegal imports of alcohol and tobacco, so there would still be an illegal trade in drugs.
I think I have more or less covered everything, except to say that most of the arguments did focus on cannabis. Our chair did a sort of straw poll at the end, and most people were in favour of change, but a lot of that change did focus more on cannabis than all drugs. I think that is about right. I think I have more or less summarised what our group said.
Q41 Dr Huppert: Thank you very much. It is a tough job to summarise most of these discussions. Part of the problem is that no two people in a room will remember a discussion in exactly the same way. Thank you to all the rapporteurs for reporting back. I hope it was helpful. If you feel there are things that should have been said that you did not have a chance to say, we will still take short comments-factual information, ideally, rather than opinions. I think we have a good sense of opinions, but if there are urgent facts that need to come in, they can still be sent in by e-mail quickly, in the next week or so.
Before I hand back to the Chair of the Committee to introduce our final session, I want to try something. A recent poll suggested that 75% of Members of Parliament thought that the drug policy was not working. Two questions have helpfully been drafted for me. This is a straw poll. It is not in any sense going to be indicative of public opinion or anything like that, because you are not a randomly selected group of people. These questions are massively over-simplified. Roughly how many of you would support something like the current policy? How many of you would support something like a decriminalised system? And how many would support something like a legalised and regulated system? Those are the three options, and you can vote for only one of them, though I know they are crude.
How many people would keep things roughly as they are? Is somebody counting? Roughly how many would go for some sort of decriminalisation? How many would go for some sort of legalised and regulated system? I realise these are not perfectly defined, and it would be a lot of work to write a law based on those words. I have one last question. How many of you think that we can have a drugs policy that is acceptable to everybody? Hands up if you think it is possible. We have a few people. Thank you very much.
Q42 Chair: Thank you very much, Julian. I assure you that we are not going to write the report on the basis of that show of hands. I thank Julian Huppert in particular for chairing the session and for encouraging the Committee, along with Nicola Blackwood, to pursue the inquiry. Sometimes people say that Select Committee inquiries do not last long because of the current issues before the public. This inquiry has lasted a year, so it has taken a long time. It is going to take us a few sessions to agree on our report. As I said, we will have it ready in December.
Our final speaker is the Portuguese Health Minister, a former adviser to the President of Portugal. He was appointed by the Prime Minister to be the Health Minister in Portugal. Members of the Committee were able to go and see for themselves what was happening in Portugal, and we found it very interesting indeed. He speaks English better than I do, so there is no simultaneous translation. Please welcome the Minister for Health in Portugal.
Speaker: Dr Leal Da Costa, Portuguese Health Minister.
Dr Leal da Costa: Good afternoon. I am afraid you will be disappointed-the Chair’s English is definitely much better than mine.
I have only 15 minutes. It is going to be difficult to talk about what we have been doing in terms of drugs control and policies in Portugal in 15 minutes, but I will do my best. For those of you who do not know Portugal, it is a small country of about 10.5 million people. It is the most western country of continental Europe and we have a lot of seaside-so any of you wanting to go to Portugal, please enjoy the beaches. That also creates a drug trafficking problem. We have close relations with south America, mainly Brazil and other countries, and obviously some African countries, so we are exposed to drug trafficking, and we know that.
The problems with drug use in Portugal started in the 1970s when we became a democracy. We had lots of people coming from Africa who had contact with drugs in some way-mainly the military who were coming back from the war. At one stage, we had a huge problem in Portugal with heroin and cannabis addiction. We then became aware, from several surveys, that the many problems with drug addiction were a major concern for the public as a whole. From a medical point of view, it was also becoming a problem because of the rise of the AIDS epidemic. We knew we had to do something very drastic to deal with the problem. We had policies in place that were similar to what other people did then, which was criminalisation of drug consumption and putting consumers in jail.
If we accept that for most of those people drug addiction was a disease-I am a medical doctor-we considered that it would not be proper to solve the problem by imprisoning all those diseased people. So we made this move, and we decided in 2000 under law 30/2000 to decriminalise the use of certain drugs that were then considered illegal. That does not mean that we have legalised all drugs according to international standards. As a matter of fact, we have just illegalised one more-methadone-which is becoming a problem for us, and I will talk about that later. In Portugal, we are now having a problem with ketamine, as I suspect are other countries in Europe.
There was huge confusion in society as we moved to decriminalisation. People thought we were legalising harmful drugs. I believe that illegal drugs are harmful. Make no mistake: they are harmful. The problem of whether to legalise them or not is a completely different story. Even if we consider them to be legal, we are not telling people that they are not harmful. Tobacco is harmful; tobacco is a major killer in Portugal, yet it is still legal.
When we looked into those problems, we decided to create a huge structure, the Institute for Drug Treatment-IDT. We had a strategy whereby imprisonment was no longer an option for people who had a certain amount of drugs, which was considered to be a 10-day allowance. That allowance varies. For example, it may go up to 25 grams of cannabis down to 1 gram of heroin, 1 gram of methadone, 2 grams of morphine, or 10 grams of opium. It varies a lot, depending on the drug.
Then you have to ask what you do to the people who are caught with that amount of a drug, because it is illegal. They are brought before a commission that decides what sort of penalty they will get, and it varies a lot-from community service to compulsory treatment. There is one good thing about that. We have a problem with youths taking drugs, like everywhere else, so it is a way for parents to know what their children are up to, and it has been shown to be very effective.
Our policy is to achieve dissuasion, which is important as part of our prevention programme, and a big component of treatment in harm reduction. Through decriminalisation we have achieved one of our major goals: harm reduction. We have people coming forward and looking for treatment, which they would not do otherwise. We now have a community of well-identified heroin users who are in substitution programmes if they want that. Some were put into rehab programmes, and quite a lot of them have come off heroin. Through those programmes, some people have been able to find jobs and get on with their lives. In the old days, when they would have been pursued as criminals, that would not have been possible.
We obviously realise that from our point of view decriminalisation is a way of trying to prevent further harm, and of getting the message through. We are absolutely convinced that the biggest problem with drug use, at least in our country, is misinformation about its harm. That is very clear when we deal with the younger population, among whom we also have a big problem with alcohol consumption. I believe that we must tackle both at the same time. It is not just a question of looking at cannabis users among our youth population nowadays; it is probably even more problematic if we look into the use and abuse of alcohol among youngsters. It is actually a new fashion, I would say, in Portugal; being a wine producer, we had not seen it before, but now we are witnessing a change of behaviour among our youth.
It would take me quite a long time to go through all we have done under this policy, so I am just going to give you some examples of sanctions, like periodic presentation to drug addiction dissuasion commissions, sometimes warnings, community service, forbidding attendance at certain places, apprehension of objects, interdiction on travel, interdiction on receiving subsidies or other military and social grants and, in some cases, even fees. Obviously, if people are caught with higher quantities, they are actually taken to court and prosecuted by law.
Let us talk about some of our results. You heard Dr Stevens presenting them, and they were absolutely correct. I am with him; I am not saying that it was an enormous success. We are humble enough to admit that we have attained most of our objectives but that the most important part is yet to be done, which is to prevent people from starting to use drugs. So the important questions that should be addressed are why do people take drugs, why do people get drunk, why do people need these sorts of substances for recreation? Basically, that is what matters. What are the social conditions? What is the context that people live in? Are schools interesting enough for the students? Are students’ hopes for the future reasonable enough to have courage in their decisions?
These are the important questions, and we are addressing them too. To give you an interesting number, we realised recently that 30% of our university student population is taking some form of psychoactive prescription drug. This is a matter to think about; we should all think about it, because it tells us something about society nowadays. People probably need to take anti-anxiety or anxiolytic medicines for the same reason as they drink or have cannabis. The problem should be addressed as a whole.
We believe that with decriminalisation we have created opportunities for treatment, but prevention is complex and we must do something new about it. Just to give you some numbers, in Portugal lifetime consumption of cannabis is still, on average, lower than in the rest of Europe, although it has been rising a little. Our lifetime consumption of all other drugs including cocaine, ecstasy, amphetamines and opioids is much lower than the European average, despite decriminalisation. We had a sharp decrease in HIV-related deaths for drug users; unfortunately, we have not been as fortunate with sexual transmission, so we have seen a tremendous rise in the heterosexual population and also, lately, in the gay community. In Government now we are obviously very worried about it and will do our best to avoid it.
We have problems, as you also mentioned, with drug consumption in prisons. We are doing our best to tackle the problem. We decided not to ignore it; we accept that it exists and that we must do something to prevent it, including getting better treatment for inmates. I have to be honest, however; I believe that another measure we have taken that would not be possible had the use of heroin not been decriminalised is a big-very expensive, by the way-programme of needle exchange for drug users. This is one of the most effective ways we have found to reduce HIV infection in Portugal. It has been working and is worth every penny it costs.
I could speak about decriminalisation for a long time, and I hope you believe that what I have told you is absolutely true. We have not seen a rise in drug consumption in Portugal. We have not seen any cause for social alarm. People are not killing each other because of drugs; not as much as because of jealousy, which is actually the main cause of murder in Portugal-passionate killing, not drug homicide. So beware if you fall in love in Portugal and think about betrayal; it is better to have cannabis-or safer, I should say.
Nevertheless, I must end my talk by re-emphasising one of the biggest problems we now have. I am just going to take one minute more, because I am in the UK and I cannot afford to lose this opportunity. According to reports, the UK is the largest source of internet legal highs in Europe, and probably the world. We must address that with courage. In the past year, our authorities seized €431,446.70 of material from smart shops, including fertilisers, detergents and a few other things that people ingest or inhale.
Being a doctor, while emphasising that drugs are harmful, that I am not keen on having them and there are lots of studies to be done, I believe that I am today actually more afraid of the so-called legal highs of which I know nothing. It is better to deal with the problem we know, with substances we have known for years, and which in some cases we have been using medically, than be faced with the scourge that is the use of toxic substances used as substitutes for drugs. That is something we must all face, and, again, it needs a very important, co-ordinated effort all over Europe. Thank you very much.
Q43 Chair: Thank you very much. I know that you have your own Select Committee to appear before.
Dr Leal da Costa: Yes.
Chair: But that is the Health Committee, and there are a couple of questions from Home Affairs Committee members. Alun Michael wants to ask you a question.
Q44 Alun Michael: Thank you very much for an excellent talk. It was very informative. At the end, you threw us a challenge. May I reciprocate by asking, what co-ordinated action? What steps are needed? Your challenge to the UK is entirely reasonable. Would you like to go a stage further and give us the solution?
Dr Leal da Costa: Thank you very much; I knew something like this would come up. I believe that this is not just a question for the UK and Portugal. It is a European question. I am just going to tell you about the experience we had recently in Madeira, which is an autonomous part of Portugal. They decided to pass a law that would prohibit smart shops, and it was deemed unconstitutional in Portugal.
This is a huge problem, because the major problem is defining the object. The greatest challenge, and for this I do not have a quick answer, is defining the object we are chasing. What people do, at least in my country, is say that they do not sell the substances for human consumption, so when we go into a shop-we have two authorities that do that with the police-and see a small flask containing something with an invented brand name that says that it contains fertiliser and is not suitable for human consumption, we have to use the laws that regulate fertiliser sales in order to deal with it.
Obviously, sometimes policemen disguise themselves as buyers-we have quite a few of them. They try to buy, and then people are caught in the act of selling something-"Oh, but how do I take this?"-and they explain very thoroughly how one takes the thing. Then they are caught because they are actually doing something illegal, which is selling something for human consumption outside a pharmacy. But that is as far as we can go.
It is a big challenge, and I think we should all go back to the drawing board and do something about it, but I do not have a straight answer now. Believe me, the biggest challenge is defining the object. With ketamine, it was relatively easy, but there are too many other things that are difficult to trace.
Q45 Mark Reckless: Minister, because of the d-word-decriminalisation-many people in this country assume that Portugal has a lax or tolerant approach to drugs. I understand that you prevent dealing and that the police have stopped it. Can you clarify what happens in circumstances when a user refuses to engage with one of your commissions to stop people using drugs? What sanctions are there, if any? What do you do when people seek to ignore the dissuasion commission?
Dr Leal da Costa: That is the biggest problem. Although we also have ways of getting people into treatment, we clearly know that the majority of people who buy and use drugs regularly sometimes get involved in other criminal activities, and that is how they are caught. But if someone goes on taking drugs, does not harm anyone, does not sell drugs and does not produce any harm to society or to those around him, there is no reason why one should go after this person. We simply do not do it. I am a medical doctor myself. Although I believe that using drugs is not good and that drugs are harmful, I think that the problem of drug use is never going to be solved by prohibition. We have that experience in Portugal.
I am not telling you it is going to be less expensive. This is another thing that I must warn you about. If you agree and accept that you are decriminalising the use of certain harmful substances and give opportunities for treatment, you must have in place good structures to attend to everybody who needs treatment. It is not necessarily going to be cheaper than putting people in jail, but apart from the humane principles that rule medicine and politics in general, one has also to consider that from the technical point of view we prefer to spend money that way.
I will give you an idea. We are going through a big challenge now. We have made a crucial and risky decision. We have transformed drug care in Portugal. We have separated the people who do the planning, health promotion and prevention from the people who do the treatment. We have moved treatment into the NHS, because we believe that it is better to have all the facilities together, and have treatment co-ordinated with alcohol treatment and the other facilities that we need to have in place, and even with mental health structures. We had a system where the treatment of drug addiction was separated from the rest of the NHS, and I believe that was the wrong idea. One of the consequences was that the people involved in treatment had less time to devote to prevention. Prevention is the key in what drug use involves. Prevention is the key, believe me.
Chair: Thank you, Minister. I thank all of you. This is a brief thank you to all those who have come from abroad, especially our friends from Portugal, Colombia, Morocco and all the other countries represented, to all those who have come from throughout the United Kingdom and to our speakers, who have been extremely helpful to us as a Committee in fashioning our views on what we should do in the report. We must continue this dialogue. Please keep in touch through our website. As we said earlier, if you have new submissions, let us have them. We are going to make decisions on this very shortly, so please let us have your views as soon as possible.
My final thanks go to our staff-Tom Healey, Ellie and all the Select Committee staff-for all the hard work that they have done. It is unusual for Select Committees to have seven hours of conferences of this kind. Normally, as you know, our witnesses sit in front of us and are very politely treated by members of the Select Committee. This is a slightly different format, and it has been very helpful in enabling us to canvass a wider range of views. Thank you to Alun Michael, Nicola Blackwood and Mark Reckless for staying through to the very end.
May I ask people to leave their name badges? In this time of austerity, I am afraid we are going to recycle you. You will become someone else for the next seminar. In the meantime, thank you very much, and please keep in touch.