Hope on the horizon for our overlooked Tier 4 services

The effects of the era of austerity on local government commissioned drug and alcohol treatment and recovery services have been well documented by Collective Voice and others. But ours is not a straight-forward system. The localist philosophy animating the Health and Social Care Act of 2012 has resulted in local ecosystems existing with quite different climates of resource, political leadership and population need, all at a time of savage reductions in the local government settlement provided by Westminster.

But even within this overall reduction in spend, certain elements of the system have fared particularly badly. The two vital interventions which support people with the most acute or complex needs – residential rehabilitation and detox, sometimes collectively described as ‘Tier 4’ services – have really struggled. Unlike community treatment, which is funded and commissioned directly by the local authority for a number of years at a time, rehab and detox are usually paid for through a mosaic of spot-purchasing frameworks.

And as budgets have been squeezed, the helpful block purchasing of beds which helped bring in resource in the past has become less and less common, and those responsible for the Tier 4 budgets have, perhaps unsurprisingly, felt unable to commit as much as resource as they’d like to services which could benefit those for whom community support is not enough. For residential settings, almost a quarter of local authorities refer fewer than five people annually.

Consequently, the once well-trod pathway from community treatment to residential rehabilitation via detox has become degraded. A very real lack of resource and a lack of awareness of how detox and rehab can help have become mutually reinforcing, worsening the problem. Frontline workers are unlikely to be confident in putting forward clients for rehab if they think there isn’t enough money in the system to pay for it, or that rehab ‘isn’t something we do here’. The challenges of Covid-19 only intensified the issue, with some community providers forced to scale back support and move to remote support, placing further stress on the pathway.

This has contributed to a major dip in the numbers of people accessing inpatient and residential settings. The figures are particularly stark when compared with our European neighbours; just 0.5% of England’s in-treatment population is in a residential rehabilitation setting, against a European average of 11%.

This latest dip in referrals due to Covid-19 is just the latest in a trend that has been going on for years. For Tier 4 services as a whole, 2019/20 saw 15,161 getting help, down from 16,757 in 2018/19, an 11% drop. The 2019/20 rate is 41% lower than 2014/15 which saw 25,847 receiving this kind of help. About two thirds of those receiving support from a Tier 4 service do so in an in-patient settings; one third from residential rehabilitation.

This reduction has happened despite the recommendation in our national evidence-base on the efficiency of both rehab and detox as essential stepping stones in the pathway of recovery. ‘Drug misuse and dependence: UK guidelines on clinical management’ (the ‘Orange Book’) and NICE both detail the role both forms of support can play for the those with the most complex needs.

This context makes the recent announcement of £80million funding for drug treatment particularly welcome. Though some may – quite understandably – critique its criminal justice framing the new money surely represents a welcome life-raft of support for a field starved of resource. The funding’s universal strand (the largest part by far) which all local authorities will benefit from can be spent on rehabilitation whilst there also exists a specific strand for detox. This focus on detox is very welcome and should enable commissioners to fund support from a range of local and national detox units as dictated by cost-effectiveness and local need.

Increased funding is a necessary but not sufficient condition for sustained change. These pathways must be kept open. The charting of a possible route to a healthy system with improved Tier 4 pathways has begun with the announcement of the 80 million. The next step must be the publication of Dame Carol Black’s Independent Review of Drugs. We believe this should happen soon and that as a field we must all apply as much pressure as we can upon its release to ensure it gets a fair hearing in political terms.

To continue this discussion Collective Voice is hosting a webinar on 4 March which will take a systems lens to residential rehabilitation and detox support, contextualising it within the Black Review and the recent £80million funding for drug treatment. Join us!

We’ll be joined by Hannah Shead (CEO of Trevi House), Jon Shorrock (Services Manager at Avon and Wiltshire Mental Health Partnership NHS Trust), Rosalie Weetman (Public Health Lead at Derbyshire County Council, Annemarie Ward (Chief Executive of FAVOR UK), Andy Symons (Senior Operations Manager at Turning Point), Pete Burkinshaw (Alcohol and Drug Treatment and Recovery Lead at Public Health England) and the event will be chaired by Karen Biggs (CEO of Phoenix Futures).


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