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Another reply to the consultation comes from 18 drug organisations which have put together a paper on residential treatment. Residential treatment is known to be the most successful way of treating people who are addicted, but it takes time. The trouble with too many of our treatment programmes is that they are short and that people do not get full value from them. Yet the figures show that our residential homes are not as full as they could be, and some have had to close. I commend the fact that the report includes these 18 organisations. Not all of them are involved in residential treatment; a number of people are involved in either harm reduction or addiction programmes, and they support the case for these. They have the sense that too many areas will not place people in treatment programmes that run for more than three to six months. This is simply not sensible when tackling deeply entrenched behaviour. My concern is that I find no evidence in the consultation document that that sort of view from people on the ground is being sufficiently noted.
Finally, my conclusion that prohibition has been excluded is derived from the fact that it is not mentioned in this consultation document at all; nor is legalisation or prescription. It assumes that this policy, which has been pursued and has failed, is to go on. I therefore do not believe that this consultation document is a worthy one on which a future strategy should be based. Too much of the evidence is suspect. Most particularly, I do not believe that all the things that have been proven to work, even though they cost money, have been included. I agree very strongly with my noble friend Lord Cobbold that a commission, rather than a consultation document that does not include proposals, is needed to go into not only the aspects which the Government choose to include but all the aspects that are known to people, including the problems of the prohibition, legalisation and prescription of drugs. The latter must have a role because, as sure as anything, what is happening now is failing, and we as a country cannot afford to go on allowing that to happen.
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6.27 pm
Lord Brooke of Alverthorpe: My Lords, I am associated with several charities in the drug and alcohol field, but today I speak particularly as a trustee of Action on Addiction, which is well qualified to offer a meaningful contribution to the new strategy. It operates long-established treatment services in both the residential and non-residential sectors, such as Clouds House, which are acknowledged as some of the best in the country. It has facilitated cutting-edge research, and has shown leadership in the development of services for families affected by addiction, including children, through its Families Plus service. It has also established world-class courses for training addiction counsellors at its centre for addiction treatment studies.
My contribution will probably be a little different from that of most who have spoken so far, as it focuses on the treatment, family support, workforce development and research sections of any new strategy. On the issues that others have addressed tonight, my view is that, regardless of whether we decriminalise drugs or have more effective enforcement, people will continue to suffer from addiction, and they need help to recover from it. After all, alcohol is legal and has been deregulated. Do we have addicts? Of course we do. We have an increasing number of addicts; there are four times as many addicts of alcohol as there have ever been addicts of drugs. We must bear some of those issues in mind when we consider how to deal with the nuts and bolts of addiction and with addicts, which is the purpose of my contribution.
A significant amount of money has been invested over 10 years of drug treatment. As a result, we must acknowledge that more people have had access to some kind of treatment and, somewhat late in the day, we are starting to see a growing recognition of the need to provide proper support to families and carers, including children. In some areas, there have been clear improvements in commissioning and service provision. However, while some improvements have been made over the life of the current strategy, they are not wholesale across the board or deeply rooted, and much more needs to be done to ensure that we continue to make further progress both in treatment delivery and in the systems within which treatment services must operate. To do so, we must learn the lessons of the past 10 years and act accordingly, and I bring that home to the domestic scene rather than the international one.
First, given the extent of the problem and its national impact, it is a scandal that so few people who need treatment for alcohol dependence are able to access it: currently, only one in five, according to Alcohol Concern. That is an over balancing of the direction of resources in the drug treatment field. I am not arguing that the amount of money spent on drug dependency should be reduced, but there should be a better relationship between expenditure on alcohol and drug addiction than we presently have instead of having separate silos. The national treatment agency is the National Treatment Agency for Substance Misuse, not only drug misuse, and if it is to continue it should be allowed to act according to that encompassing remit.
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We must avoid repeating the mistake of over investment on treatment obtained via the criminal justice system; most of the debate so far today has been about that. If things continue in the same way it will be at the expense of voluntary access to treatment. There must be a balance, otherwise we will continue to see the perverse situation of addicts committing crimes to get treatment and those who could otherwise have avoided the criminal justice system by entering treatment, being caught up in it. It is important that we avoid that.
Treatment should be obtainable in a timely way that takes advantage of any appearance or increase in the addict’s motivation to change, something that the noble Baroness, Lady Finlay, has raised previously. We should continue to ensure that a harm reduction platform is secured in order to stabilise those with chaotic lifestyles that have such a widespread damaging impact. But we must ensure that the process does not stop there, as it has tended to do over the past 10 years, with thousands piling up in a methadone cul-de-sac. Everyone should be offered and encouraged to take the opportunity to make meaningful progress to a life completely free of drug dependency. High on my wish list would be a drug strategy that fostered independence and abstinence if possible, not a dependency on other drugs.
Next, we must undo the equation that treatment inevitably and exclusively means medical prescription, and recognise that psychosocial interventions are, in the end, likely to play a key role in preventing relapse to illegal drug use. If we know that various forms of social support are key to sustaining recovery, we should ensure that we target adequate resources to that purpose. We must continue to ensure that pathways of care are commissioned, rather than unrelated treatment, rehabilitation and care episodes—where everything is dealt with separately and never brought back together through pathways of care. We must cease the obsession with outputs—numbers in treatment—and focus on outcomes and the quality of treatment inputs needed to achieve them.
At the moment, “in treatment” can mean anything and very little, and result in the experience of being caught in a rapidly revolving door or endlessly treading water in a sea of prescriptions. It is all very well for the NTA to trumpet 180,000-plus people “in treatment”, but that says nothing about the quality and effectiveness of that treatment. As the NTA itself has said, quantity without quality is a waste of resources. It also wastes lives and exacerbates and demoralises people. Commissioning and purchasing should be driven by the need to secure targets related to volume and price.
The quality of commissioning, purchasing and care management needs significant improvement in many areas too. Training is essential to achieve this. For a start, there should be consistency across the country, and more controversially, I suggest that we should divest from poor quality, wasteful NHS services in this arena. I know that that will upset many of my noble friends within Government, but money is going in and in many instances it is not producing the results that it should. If that money was directed to the voluntary
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I move to a separate subject. We must rationalise the current wide variety of regulations and standards and produce a coherent, workable system that can be applied across all the models of care. I suggest that we should make a start in the area of residential treatment and see whether we can introduce some standardisation and commonality of approach. Gradually, we could then roll that out over a wider area. Further, if we want to make the most of the voluntary sector’s considerable expertise, we must be prepared to keep to the commitment that voluntary organisations are able to recover the full costs of providing services in line with voluntary sector compacts. We must rigorously examine the ratio of spending on bureaucracy to that of spending on actual service delivery and training. Why should good services that directly benefit people’s lives struggle for resources while new government agencies grow and grow, consuming funds? As an aside, we seem to have far more conferences and receptions. I suggest that a good start would be to halve the conferences and receptions planned for the coming year. We would then release a significant amount of money that could be put on the front line to assist addicts and their families.
Turning to families, there are many more people affected by substance misuse than there are substance misusers. The evidence of the impact on their lives suggests that this constitutes a major public health issue and should be addressed as such. The health and cost benefits of providing proper support to families affected by substance misuse are likely to be very significant indeed. I would argue that the key recommendations published in HiddenHarm should be implemented without delay. That would ensure that the 1.3 million children of substance misusers receive the help they desperately need. Action on Addiction has developed an effective brief intervention called M-PACT that supports these children, and which we are now aiming to make more widely available across the country. I would be happy to show the details of that intervention to my colleagues on the Front Bench if they would like to examine them in the context of the strategic review.
A competent workforce is also essential to quality and effectiveness, but it is no good highlighting how important workforce development is, noting the continuing deficiencies in knowledge and skills, while at the same time failing to provide any tangible support to those like Action on Addiction’s Centre for Action Treatment Studies. We need to resist investment in short-term, superficial training, which has little lasting impact, in favour of courses that produce competent professionals
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I believe that we have made some progress over the past 10 years—I am not as critical as some of the previous speakers in the debate—but there is much work to be done. If we begin to address some of the nuts and bolts issues in detail in the way I have endeavoured to address them, as well as looking at the wider national and international issues, we have a prospect of making more progress in the ensuing strategic period of the next 10 years.
6.40 pm
Lord Adebowale: My Lords, I apologise for missing the Minister’s opening of the debate and the contributions of the noble Lords, Lord Mancroft and Lord Cobbold. I was told the debate was starting at 6.30 pm and I had to go and earn a living. I apologise to the House for my late arrival but, even having arrived late, I have listened to some excellent contributions. I hope that I can add some value to the debate from my position.
There is a sense of déjà vu or groundhog day whenever there is a drugs debate; the issue becomes one of legalisation versus prohibition. I do not want to go there, save to say that the remarks of the noble Lord, Lord Brooke of Alverthorpe, are common sense: we need to start from where we are as opposed to where we wish to be with our drugs policy. The question here is about treatment and, in that regard, I should declare an interest as a member of the ACMD, that much maligned but interesting group of people, and as the chief executive of the social care organisation, Turning Point, which I am told is the largest provider of substance misuse services in the voluntary and/or third sector in the country. We have a body of knowledge from which to speak and that is why I thought it would be useful to contribute to the debate.
Turning Point provides services across the range, from tier one to tier four, and this includes both community and criminal justice services as well as residential services. For the majority of our service users, substance misuse is only one of a range of complex needs which contribute to their social exclusion. We need to take this on board in discussing the drug strategy if we are not simply to do what we have always done. If we do, as Einstein pointed out, we will get what we have always got, which is a sense that we have not moved much further from where we are.
Let me give your Lordships some facts. Half of the people we see at our drug and alcohol services suffer from mental health problems. Around half of those accessing drug and alcohol services have mental health problems, according to the Department of Health’s own figures on dual diagnosis, and 84 per cent of homeless people have drug or alcohol problems. Regardless of which side of the House you happen to sit, we need to acknowledge that the Government have made major strides in drug policy over the past 10 years. You may argue that getting people into treatment is not enough,
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I further agree with the comments of the noble Lord, Lord Brooke of Alverthorpe—the noble Lord, Lord Ramsbotham, also made these points—in relation to the criminal justice system and the balancing of investment to ensure that we do not get perverse incentives. I have received letters from fine, upstanding middle-class members of our community who have had sons and daughters commit crime in order to access treatment. It is not the intention, but there is a perception that there is a fast route to treatment through the criminal justice system which I would like to see rebalanced.
So what do we do? Where are the solutions to be found? Let us take a forward looking, positive approach to what can be done. We need to deal with and manage better wrap-around care. It is time to build on the success of the past 10 years and not denigrate it for its failings. We need a new drug strategy which is ambitious for substance misusers and ambitious about their potential to re-enter and contribute positively to our communities. It is not always a dead-end for many of Turning Point’s and other services’ clients. The Government must build on the existing framework so that treatment encompasses the full complexity of substance misusers’ needs and provides wrap-around support to enable them to take a full role in society.
The areas of people’s lives that need specific support are employment, housing support, healthcare and issues such as support on leaving the criminal justice system. My own organisation and others—I am not simply going to advertise Turning Point—have specific measurable outcome-focused programmes that have been shown to work, and require further investment and attention for those programmes to be rolled out so they are working everywhere, not just in the places that are lucky enough to have them. Those services are the stepping stone allowing current and former drug users to become citizens again—positive citizens—and that must be the aim of the Government’s drug strategy, along with moving them away from the social exclusion that substance misuse can create.
Helping drug users into employment and providing stability links in with the Government’s agenda on increasing the number of people in paid employment, reducing benefit dependency and targets for social exclusion. It is imperative that people do not fall off the end of the conveyor belt of the treatment journey with no ongoing support. The drug strategy must make wrap-around care an essential part of a drug user’s treatment journey, not an add-on or an optional extra. There must be clear targets for commissioners and providers to prioritise these essential services to deliver more integrated and effective solutions in drug policy.
If you simply set targets, they will be reached. We have all come across the concept of “gaming”. What we know and what we need to learn is that organisations
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Turning Point and others recommend an integrated approach to the treatment of substance misuse through extended interpretation of treatment to encompass these wrap-around services and aftercare support. I would also include financial advice and housing support as part of the integrated treatment process. We recommend that the new drugs strategy includes a target focused on the requirement to provide integrated aftercare support for substance misusers, built into their treatment plan. That must also include support for the more problematic users and specific aftercare support for offenders.
Since the publication of the previous drugs strategy, patterns of drug use have changed. The new strategy needs to reflect that and develop new services to build on current provision. The increasingly complex needs of drug users, as the noble Baroness, Lady Finlay, mentioned, and the lack of tailored and flexible accessible services to respond to those changes are a significant challenge for the Government over the next 10 years. The Government must address the wholesale absence of treatment systems specifically for crack and stimulant users and for those with dual diagnosis of substance misuse and mental health problems. With half of substance misusers already having a mental health problem, as I have mentioned, the Government cannot afford to ignore the needs of that client group who may access services only when a crisis point has been reached, often becoming NHS “frequent flyers”, clogging up A&E departments and becoming the very people who cost us the most.
Users of other substances often turn up at our services simply because they have nowhere else to go. That includes those with problems with the stimulant khat, those using prescription drugs and steroid users. Alcohol misuse is a significant problem affecting individuals. It feels like déjà vu to say it, but we plead with the Government to take due care about what is said about alcohol. It is a significant challenge to the social infrastructure of this country and the Government need to pay attention to that. Alcohol services are less common than drug services and less likely to be part of a co-ordinated response with other agencies; for example, with children’s services. Turning Point’s own report identified that tonight one in 11 children will have gone home, if it can be called “home”, to a place where their parents or carers are misusing alcohol. I emphasise that: tonight. We are calling for a national inquiry to investigate fully the scale of the problem and identify recommendations for service delivery to support those families.
In order truly to come of age, the next drug strategy should be an integrated substance misuse strategy that covers all problematic substance use. It is essential that the new drug strategy addresses dual
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In addition, the new drug strategy needs to turn its attention to blood-borne viruses. We at Turning Point are concerned that, despite the welcome and necessary increased investment in drug treatment, there has been an alarming increase in blood-borne viruses. We contacted nearly 900 injecting drug users across England and asked them about their injecting practices and blood-borne virus status as part of our report on blood-borne viruses, At the Sharp End. Our findings are truly alarming. There is a new generation of injecting drug users, using heroin and crack together, who are at greater risk of infection and may not have been tested or received treatment for their illness. We recommend that the new drug strategy sets out a clear commitment to reduce the transmission of HIV, hepatitis B and hepatitis C and improve access to treatment with clear targets to ensure delivery. This is a public health matter; it is not an issue just for the drug-using community; it will affect us all and the generation to come. We must act.
In too many drug action teams there is an inadequate understanding of commissioning. Commissioning should be the means by which one understands the needs of the client, and/or the community in which they live, to build a platform for procuring appropriate services. That often does not happen. One gets cheap purchasing of the cheapest service, which is why residential services are not often focused on and there is often an odd mismatch between what the NHS provides, because of its relationship with the commissioners, and what the voluntary and third sector provide. Commissioning must be clearly defined, and commissioners must be held accountable for the process of commissioning drug services. They must be able to audit and provide evidence of the methods that they have used to understand the needs of their community.
I have a positive attitude toward the Government’s drug strategy. Much has been done that must be acknowledged, but there is much yet to do—to coin a phrase. I shall end with a story, because it is important that we bring the individual into the debate. I shall talk about someone who represents the aim of the Government’s drug strategy, which is to produce positive citizenship in our approach to treatment.
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