Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Adfam (DP076)

Adfam is the national umbrella organisation working to improve the quality of life for families affected by drug and alcohol use. We do this by working with a network of organisations, practitioners and individuals who come into contact with the families, friends and carers affected by someone else’s drug or alcohol use. We provide direct support to families and practitioners through publications, training, consultancy, prison visitors’ centres and signposting to local services, and work extensively with professionals and Government to improve and expand the support available to families.

Throughout this response, the term “families” is used to refer to relatives or close friends affected by someone else’s drug use. This includes parents and carers; spouses and partners; children and siblings; grandparents; extended family members and close friends with respect to those supporting current drug users, recovering users and those that have been bereaved by drug use.

Summary of Key Points

Drug treatment is more likely to be effective, and recovery to be sustained, where families, partners and carers are closely involved.

The inquiry is considering the criteria used by the Government to measure the efficacy of drug policies; but as the Drug Strategy does not include a clear framework for action and evaluation—particularly in relation to work with families—there may be gaps, meaning the strategy will be difficult to evaluate.

Increased localism is admirable but may risk inconsistencies in services across local boundaries and disinvestment in provision for vulnerable people, especially without ringfenced money.

Small, community-based organisations such as those supporting families need support to adapt to new systems of commissioning, particularly Payment by Results.

Adfam would Welcome the Opportunity to Submit Oral Evidence to the Committee

1. The Drug Strategy

1.1 Adfam welcomed the recognition of families in the Drug Strategy, including the harmful effects of drugs on family life; the effectiveness of family-focused interventions in prevention work with young people; the effects of parental substance use on children, and the harms it can cause to them; the cost savings of intensive whole-family interventions; the valuable “social capital” provided by families in the recovery journeys of substance users; and, crucially, its statement that “treatment is more likely to be effective, and recovery to be sustained, where families, partners and carers are closely involved”.

1.2 The strategy also says the Government will “encourage” local areas to “consider” support for families in their own right; however, this does not mandate any action, does not explain what form this “encouragement” will take, and does not mention a framework of evaluation. There is a clear risk that without more robust strategic direction and guidance, local areas will disinvest in vital services for vulnerable people. It is Adfam’s view that families should not be expected to contribute to a relative’s recovery without concurrent support for their own needs—they are not simply a source of “recovery capital”. For example, the UK Drug Policy Commission states that they experience harms amounting to £1.8 billion per year, as well as providing £750 million of support for their families.1 Support should be available for them across the board, and without this their capacity to support other people’s recovery will be reduced.

1.3 With the Government’s move towards greater independence for local areas, the Drug Strategy is not expected to be highly prescriptive; there are many positive opportunities for communities to design and implement responses to the problems they know best, and it is up to them how to allocate resources to the most important and effective initiatives. However, the changes the strategy claims it will cause will be difficult to measure effectively without some commitment and leadership from central Government. If local areas are left entirely to their own devices, Government must be prepared for the eventuality that they may fail in their service provision. In this case, it is families and service users who may suffer.

1.4 A lack of drive and guidance from Government—including around minimum standards—runs the risk of causing confusion, inconsistency and disinvestment as local areas are unsure of effective approaches to problems, introduce different ways of working with varying results, and do not allocate money to services for substance users and their families at all. This is not an argument for centralism, but a recognition that Government is more likely to be in possession of the full facts (for example evidence on effective drug education in schools, the best ways of involving families in treatment, and the most successful crime reduction initiatives at local level), has a role in distributing good practice and learning, and has a clear interest in making practice as effective as possible.

1.5 Budgets are tight and with an increase in local accountability—including the introduction of local Police and Crime Commissioners, who will likely be asked what their approach to “the drug problem” is in the run-up to elections—decision-makers may find themselves hard-pressed to justify spending public money on unglamorous groups like drug users and their families. Without a ringfence for funding, it is vital that the Government plays some leadership role in ensuring that local service provision is adequate and follows best practice.

1.6 The strategy also pledges to reduce demand by providing “good quality education and advice so that young people and their parents are provided with credible information to actively resist substance misuse”. To achieve this goal it is vital that evidence-based educational approaches are employed. The Drug Education Forum (www.drugeducationforum.co.uk) is a centre of knowledge in this area, so it is unfortunate that it will no longer receive Governmental funding after the end of this financial year. The drug environment is not a fixed one—see, for example, the emergence of “legal highs” and the proliferation of false information, confusion and hearsay around them—so organisations with expert knowledge in the drug education arena should have an ongoing role.

2. Payment by Results

2.1 Payment by Results is a key feature of the Government’s approach to public spending as it relates to drugs and recovery. This is of course based on the sound principle that services in receipt of public money should be conducting demonstrably effective work. However, the introduction of new ways of working to a sector which is unused to such practice, is largely composed of small, independent voluntary sector providers (particularly as far as family support is concerned); and works in “hard to measure” results entails a great amount of risk.

2.2 Where vulnerable families are concerned, improving their health and wellbeing is rarely a question of the work of one service: outcomes are secured in partnership between various organisations, for example peer support, counselling services and health professionals. So with outcomes that are difficult to measure at the best of times, this clouds the picture even further. There is a risk that if narrow outcome measures are introduced which relate only to individual service users, this will make the system more atomised and centred on the individual, rather than looking at the whole context of the family, children and community—after all, substance use does not exist in a vacuum and is surrounded by myriad causes and consequences involving many other people.

2.3 The Drug Strategy listed “improved relationships with families, partners and friends” and “the capacity to be an effective and caring parent” as key outcomes in a recovery-focused system of commissioning. However—disappointingly—these were omitted from further work on outcome measurement such as the Department of Health’s Final Outcome Definitions for the drugs recovery pilots being held in different sites across the country. Outcomes in the new drug recovery system should be selected on the basis of how important they are, not how easy or difficult they are to measure.

2.4 Though the strategy itself states that “central Government will not seek to prescribe the approaches that should be taken in delivering these outcomes but will instead carry out research to develop and publish an evidence base as to ‘what works’ in promoting the sharing of best practice”, there is again a lack of information on what form this will take and how it will be carried forward.

2.5 The introduction of Payment by Results also presents serious practical difficulties for smaller organisations due to a lack of historical data collection with which to demonstrate their effectiveness, and a lack of reserves or capital to manage the transition to future payment for outcomes instead of advance payment for services. These organisations should be supported to implement effective monitoring systems to help demonstrate their effectiveness in more robust ways, and new systems should be introduced gradually so these support services can catch up to new ways of working and their expertise is not lost.

3. Transition from the NTA to Public Health England

3.1 The current public health reforms and the transition of the functions of the National Treatment Agency to Public Health England present a number of possible risks, as well as some opportunities, regarding support for families affected by drugs and alcohol.

3.2 In terms of basic funding, there is a risk of serious disinvestment through the loss of any funds ringfenced for dedicated drug and alcohol treatment or family support. It has been suggested that the final budget for public health will stand at around £4 billion, £1 billion of which will come from current drug and alcohol funds; although this £4 billion will be ringfenced for public health, no ringfence will exist within that for substance use, and the health and wellbeing boards that sit within local authorities will be able to use it to meet any of their responsibilities for a wide selection of competing demands under the broad banner of public health. This greater autonomy at local level could mean that funding is used to address any issues deemed to have sufficient local priority and can legitimately be described as a “public health matter”, with unattractive areas of public health—such as drugs—neglected. There will be no legal compunction to provide a complete drug and alcohol treatment system, or to provide support for families in particular.

3.3 As well as a potential loss of funding, this lack of ringfence could lead to a lack of focus on meeting the needs of those affected by drug or alcohol use in terms of general policy and priority. Good work has been done in demonstrating how families contribute to the recovery of substance users and how important it is for families to receive support in their own right; it’s essential that this is not lost in the broad process of meeting public health outcomes, and that “drug and alcohol services” does not simply equate to treatment for individuals without the full-family recovery Adfam has long championed. Effective support for the recovery of drug or alcohol users and their families is essential in reducing the personal and public harms that substance use cause, and in bringing down the costs to the NHS and criminal justice system.

3.4 The voices of families often struggle to be heard and every effort must be made to ensure that transition does not worsen this situation. Families are experts of their own experience, and their input and advice on priority setting in the commissioning process can be invaluable in helping to shape services that meet the needs of substance users and their families. A platform must exist that allows vulnerable voices to be heard and have a say in setting priorities. The creation of HealthWatch represents an excellent opportunity for this to happen, and for a plurality of opinion to be nurtured that informs commissioning, with the voice of families respected as expert and useful. Adfam encourages any step which increases the involvement of families and carers in the commissioning process. Local authorities will have a duty to ensure that their local HealthWatch is functioning correctly, and one of the measures used to assess the efficiency of HealthWatch should be its involvement of families.

3.5 Adfam also welcomes the opportunities reform will bring to level the playing field between drug and alcohol service provision. Alcohol support has in many regions lagged behind drug treatment—ideally the redrawing of priorities should be used to erase this discrepancy and improve support for problem drinkers and their families.

4. Stigma

4.1 Many family members describe a sense of stigmatisation from the community, other family members and friends when one of their loved ones is using substances. The deep sense of shame and stigma that families feel can lead to a reluctance to access services; children affected by parental substance use can feel isolated and alone, or be bullied by other children. Families can even face prejudiced or judgemental comments whilst they are grieving for a loved one who has died through drug and alcohol use.

4.2 Much of the general public’s information about substance use comes from the media and as such, some of their use of language and terms filters into everyday conversation. By using terms such as “junkie”, “crackhead” or “wino” to describe someone who is using drugs or alcohol, the media conveys a very derogatory judgement on that individual and indicates these are acceptable terms to describe them. For families who are impacted by drugs and alcohol, the use of these terms can be distressing and add to their sense of shame and isolation. Every one of those individuals described by news sources is someone’s son or daughter who deserves the respect and dignity of any other human being.

4.3 Drug and alcohol use touches many millions of people across the country and it is likely that many of us will know people who are affected; however, it is often stated that substance use occurs on the margins of our society and is somehow an indication of family failure or collapse. As the UK Drug Policy Commission’s Getting Serious about Stigma survey found, almost one in four respondents agreed with the statement that “Most people would not become dependent on drugs if they had good parents”, whereas one in three respondents agreed that “Parents would be foolish to let their children play in the park with the children of someone who has a history of drug dependence”.2 These judgements can prevent drug and alcohol users and their families from seeking support for their problems.

4.4 The Lancet has argued that by “overmedicalising” addiction, there is a risk of increasing stigma, encouraging a sense of fatalism and permitting Governments to ignore the social and environmental factors that increase the risk of drug dependency.3 Addiction is a complex disorder and should be treated with compassion and empathy from professionals and the public alike. Adfam would welcome a review of policy which seeks to reduce the sense of shame and stigma experienced by families.

January 2012

1 UKDPC (2009) Supporting the Supporters: families of drug misusers.

2 UKDPC (2010) Getting Serious About Stigma: the problem with stigmatising drug users.

3 The Lancet (editorial), Volume 378, Issue 9793 pp 742 (2011).

Prepared 8th December 2012