Stranded on the wrong side of the tracks

The recent rise in drug-related deaths is startling, but there’s a more troubling aspect of both the recent ACMD report and its predecessor from the LGA and PHE: the acknowledgement that this is the tip of a much bigger iceberg of excess mortality among the long-term heroin using population. Thirty years of smoking, heavy alcohol use, poor diet, homelessness, fragile mental health, and occasional periods in custody, not to mention heroin and crack use, have taken an enormous toll. Compared to the rest of the population this cohort is at much greater risk of liver disease, compromised lung function, and a range of chronic health problems that not only enhance the risk of overdose but also lead to long-term ill health and early death.

To address this issue, Collective Voice is working with NHS colleagues and PHE to identify and share best practice. Our intention is to agree routine processes able to identify those most at risk and the evidence-based interventions we can apply to reduce the incidence of unnecessary deaths. Our hope is to make this available to all providers during 2017.

Although some interventions – smoking cessation for example – sit appropriately with substance misuse services, to significantly reduce early deaths we need to fundamentally improve the referral systems between drug and alcohol treatment and mainstream health resources. This requires action from central and local government and the NHS to address the fracture between drug and alcohol treatment and the rest of healthcare created by the current system of commissioning and delivery.

There are real merits in locating responsibility for drug and alcohol treatment with Local Authorities. As long-term custodians of place, Local Authorities have an interest in integrating drug and alcohol users into services that can initiate and sustain recovery; for example, housing, education and children’s services, even when they are not directly delivered by the Local Authority itself. The Local Authority has a vital interest in the economic well-being of its citizens, which gives them an interest in improving the employment prospects of those with drug and alcohol problems. The well understood role of treatment in reducing crime, another vital Local Authority interest, gives a continuing rationale to invest scarce resources even in hard times. Finally and most significantly, Local Authorities have an appetite for partnership and collaboration that is seldom matched in the NHS.

Unfortunately, these potential benefits come at the cost of separating drug and alcohol treatment from the commissioning of all other NHS services at the very time the long-term heroin using population is most in need of mainstream clinical services. Despite the commitment of many individual practitioners, as an institution the NHS has always been poor at engaging with troublesome marginalised populations. Registrations with GPs is limited, accessing A&E is fraught with potential confrontation, staff and other patients are discomfited, appointments are missed, the “signposts” and” pathways” beloved of NHS bureaucracy are experienced as barriers of exclusion rather than gateways to access. The result is that a population that needs to be actively supported to access healthcare is instead stranded on the wrong side of an institutional chasm.

The architects of the 2013 reforms recognised that the separation between drug and alcohol treatment and the rest of NHS provision could cause a de facto denial of access. The solution was seen as lying with local Health and Wellbeing Boards whose role was to integrate Local Authority and NHS-commissioned services into a comprehensive local system. In reality, with very few exceptions Health and Wellbeing boards show little interest in the fate of drug and alcohol users as their broader agenda has been overwhelmed by the immediate and pressing need to address the crisis in social care. The few isolated examples of integrated systems of care which exist in pockets around the country are largely based on strong personal relationships between clinical leaders rather than systematic strategic integration of services driven by need. It is difficult to accept that access to lifesaving treatment should be dependent on the friendship networks of individual consultants.

The failure of Health and Wellbeing Boards has been acknowledged in public by the Health Select Committee in its report on Public Health which reflected strong criticism contained in NHS evidence. In private Local Government leaders and staff are deeply sceptical. Until this policy failure is addressed, an increasingly frail population – many of whom struggle to comply with the demands placed on them by NHS systems – will continue to be excluded from the healthcare they need by an NHS bureaucracy to which they are invisible.

The forthcoming Drug Strategy provides the perfect opportunity for government to acknowledge that the current system is failing in one of its most fundamental tasks and identify how it can be made to work to the benefit of the vulnerable population it exists to serve.

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