About Collective Voice
Collective Voice is a collaboration of the eight largest Third Sector providers of drug and alcohol treatment services in England; together they are responsible for £380m of contracts, half the total market.
Substance misuse dependence is a significant public health concern with over two million people dependent on alcohol and/or illegal drugs. Providing preventative and treatment services for this population accounts for 22% of the total Public Health Grant. This investment yields return to local communities which varies depending on patterns of consumption between £2.50 and £8 for every £1 invested, largely from reductions in offending.
Investment in treatment has yielded dramatic reductions in acquisitive crime – the Home Office attributes 30% of crime reduction since 2001 to increased treatment availability – and has driven down levels of addiction to heroin from around 450,000 people twenty years ago to 250,000 today. The reduction in heroin use has been concentrated amongst the under-30s leaving behind a drug treatment population who are increasingly in frail health because of the cumulative impact of decades of drug addiction, problem alcohol use, poor diet, fragile mental health, and smoking. This leaves them significantly more vulnerable than their age would indicate and places a significant burden on mainstream NHS clinical services.
Marginalised services for marginalised people
Despite this, drug and alcohol treatment is not a natural priority for local authorities, the NHS or public health professionals. This places this area of activity at particular risk from the negative consequences of the proposed replacement of the ring-fenced Public Health Grant with a system of business rate retention.
These services provide for an unpopular and marginalised population seen by local electors and politicians as undeserving, particularly in comparison to alternative service user populations such as children and the elderly. Without someone in local systems to champion the agenda there is a continuing risk of deprioritisation and disinvestment.
The benefits of investment, although very significant, accrue much less to the local authority than to the criminal justice system and the NHS.
Although drug and alcohol treatment brings significant benefits to local populations, the arrangements through which local authorities, the NHS and other partners seek to agree strategic priorities are dominated by the crisis in social care funding, which squeezes out consideration of other issues.
The public health professions are more comfortable engaging with population health than championing the provision of clinical services. The amount of health harm generated by drug use is a fraction of that arising from obesity or smoking. Alcohol is a natural priority for public health but the emphasis of public health activity is much more at the population level than the clinical needs of dependent drinkers.
Partly as a consequence of the success of drug and alcohol treatment as a crime reduction tool, the focus of local policing has shifted away from acquisitive crime towards violence against vulnerable individuals and communities. Together with the exclusion of police from most Health and Well-being Boards, this has greatly diminished the police’s traditional role as the local champions of drug treatment.
For many years the lack of priority accorded to this agenda by Local Authorities and the NHS starved treatment services of resources. This resulted in dramatic increases in drug addiction, drug-related deaths and offending. From 2001, Government sought to remedy this by creating the ring-fenced Pooled Treatment Budge (PTB)t. This dramatically expanded the drug treatment system, enabling an estimated 65% of heroin users to access treatment, stabilised drug-related deaths, and as discussed above drove down crime and helped reduce levels of addiction. Alcohol remained outside this system limiting the proportion of alcohol dependent individuals able to access services to 6%. The transfer of the PTB into the Public Health Grant effectively removed the protection from drug treatment spend resulting in widespread reductions in contract value for drug treatment estimated by Collective Voice to total around 30%.
While acknowledging that removing the current Public Health Grant ring fence will give greater flexibility to local authorities, creating the potential to generate innovative solutions and improve outcomes, there is a real threat that it could also lead to further rapid disinvestment. Drug and alcohol services are delivered to a population that is politically unpopular and the consequences of disinvestment lie outside the Local Authority’s direct areas of responsibility.
Collective Voice members and other treatment providers have responded to the reductions in contract value through innovation and driving efficiencies, but as the Health Select Committee has pointed out in its recent report Public Health post-2013, the scope to deliver further cost reductions without significant negative consequences is becoming very limited.
Further disinvestment would also have negative consequences for the NHS and the criminal justice system. Despite the reduction in the local priority given to acquisitive crime by individual police services the Home Office is acutely aware of the continued role of drug treatment in providing downward pressure on volume crime. The Modern Crime Prevention strategy, published in March by Theresa May when Home Secretary, identifies drugs and alcohol as two of the six main drivers of crime, and drug treatment as the most powerful means to control drug-related offending.
Similarly, Simon Stevens, Chief Executive of NHS England, in evidence to the Health Select Committee in June, made it very clear that the consequences for the NHS of further disinvestment from drug and alcohol treatment would be severe.
“At the very least we wanted the availability of preventive services to be sustained relative to need. An area where you get a very quick payback, or indeed a worsening of the situation if those services are not there, for example, is drug and alcohol services and sexual health services. If the services diminish, that shows up as extra demand in more expensive parts of the National Health Service within 12 months, not within 10 years”
The Secretary of State for Health remains accountable to Parliament for the nation’s health and the operation of the public health system. When the current arrangements were instituted in 2013 much was made of the Secretary of State retaining a clear line of sight to the reality on the ground to enable this accountability to be discharged.
To ensure that any new funding arrangements are robust and equitable the Secretary of State needs to be satisfied of the following:
- The redistribution between local authorities that will need to accompany any move to full business rate retention reflects the very real discrepancies in need between areas. Drug and alcohol dependence and the harms that are associated with dependence are closely associated with poverty and unemployment. Failure to adequately reflect different levels of need will undermine the new system.
- Sufficient investment and priority is being accorded to drug and alcohol treatment in each local authority to maintain a national system of provision. This is particularly important in respect of services focused on reducing the spread of blood-borne viruses.
- Local authorities do not place unnecessary burdens on their neighbours by disinvestment from drug and alcohol treatment so as to cause additional cost pressures in NHS and criminal justice systems operating across a multi-local authority footprint.
- An appropriate balance is maintained between local priorities and central government’s obligation to the electorate and parliament to discharge its business. Local drug and alcohol systems should therefore be expected to be able to meet the legitimate expectations placed on them by the criminal justice system to reduce crime, by the DWP to reduce welfare dependency, and to contribute to shared central and local government responsibilities such as safeguarding and Troubled Families.
- Finally the Secretary of State has a moral obligation to ensure that citizens are not excluded from healthcare because of political unpopularity. Drug and alcohol treatment is a clinical service commissioned by local authorities. The route through which services are commissioned should not diminish the rights of their patients.
There is significant distrust across the drug and alcohol sector of the returns made by local authorities to Department for Communities and Local Government (DCLG). In particular, it is impossible for us as the providers of services to reconcile our local knowledge of expenditure with that reported to Government.
An analysis that Collective Voice conducted of the most recent budget figures for substance misuse services reported to the DCLG that 38 out of 153 local authorities report an increase in budget for local substance misuse services and 114 a decrease.
Those reporting an increase include Barnsley Metropolitan Borough Council who say they intend to budget for a £2.2 million increase in spending, which would be an increase of 117% on 2015-16. However, in March 2016 a paper was presented to Barnsley councillors setting out a desire to remodel and tender substance misuse services across the locality. At the heart of the paper was a proposal for reducing the budget from £5 million in 2015-16 to £3.1 million in 2016/17.
In their return to the DCLG the council in Tower Hamlets said they were increasing the budget for drug and alcohol services by nearly £1 million, up from £8.8 million in 2015-16 to £9.2 million in 2016-17. However, these figures don’t appear to match the council’s budget book, which suggests that the Drug and Alcohol Action Team expected to spend £10.8 million in 2015-16, and has been allocated £10.2 million for 2016-17.
Kent County Council’s budget book for 2016-17 says they budgeted £15.9 million for drug and alcohol services in 2015-16, compared to a figure of £15.1 million reported to DCLG. For 2016-17, the council says they plan to spend £14.9 million on these services, which is over £4 million more than is reported in their DCLG return.
There may be sound reasons for these and other disparities that we have observed, and we make no aspersions about the local authorities that we highlight here. However, we believe that there is a need for Government to assure itself that before contemplating the significant reforms that are being consulted on here that the figures that are received accurately reflect the level of spending being undertaken.
In light of our findings, Collective Voice supports the conclusions of the Health Select Committee’s recent inquiry into public health around the need for improved transparency to “enhance accountability and provide reassurance that these functions are being maintained at an appropriate level.”
Collective Voice is concerned to protect the value offered to communities and vulnerable populations from investment in drug and alcohol treatment, not protect the Public Health Grant ring fence as a matter of principle. The two key issues are the willingness of the Secretary of State to genuinely be accountable and not abdicate responsibility in the name of localism, and local systems to be sufficiently transparent to enable them to be held to account locally and nationally. To end the ring fence without appropriate safeguards jeopardises not just the lives of an increasingly vulnerable population, but also the ability of the NHS to achieve the Government’s aims for stability, and the Home Office to continue to preside over a reduction in crime rates.
 Alcohol and drugs prevention, treatment and recovery: why invest? (Public Health England)
 Morgan, Nick. “The Heroin Epidemic of the 1980s and 1990s and Its Effect on Crime Trends–Then and Now”. Research Report 79.” (2014).
 Pierce, Matthias, et al. “National record linkage study of mortality for a large cohort of opioid users ascertained by drug treatment or criminal justice sources in England, 2005–2009.” Drug and alcohol dependence 146 (2015): 17-23.
 Degenhardt, Louisa, et al. “Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: findings from the Global Burden of Disease Study 2013.” Lancet Infect Dis(2016).
 Davis, S. C. “Annual Report of the Chief Medical Officer 2013: Public Mental Health Priorities-Investing in the Evidence.” London: Department of Health(2014).
 North London council plans reveal 60% public health cuts by 2018, Nursing Times (accessed 24 Sep. 16)
 Public health post-2013 – structures, organisation, funding and delivery inquiry, Health Select Committee (2016)
 People who inject drugs: HIV and viral hepatitis monitoring, Public Health England (2016)
 Remodel and tendering of Substance Misuse Harm Reduction, Treatment and Recovery Service for Barnsley, Barnsley Metropolitan Borough Council (2016)
 Budget Book 2016-17; Managing Kent’s money responsibly, Kent County Council (2016)
 Public health post-2013 – structures, organisation, funding and delivery inquiry, Health Select Committee (2016)