Where we have come from
As is often the case, support for people with drug and alcohol problems defies easy categorisation. It does not fit easily into a box marked ‘health’, ‘community development’ or any other label. Addiction and recovery are defined by their all-encompassing nature, and the responses our society has developed are similarly broad.
The result is a complex system of support under-pinned by differing philosophies and perspectives, organisational cultures, funding streams and commissioning approaches. The medical sounding ‘treatment’ sits within a broader support offer including key-working, psycho-social support, practical measures to reduce harm in the here-and-now, family support, routes into mutual aid and recovery communities powered by voluntary action. Add in residential rehab, the crucial interface with the criminal justice system and a splash of activism and is it any wonder we have struggled to find the right set of approaches for attracting, training, and retaining the multi-disciplinary teams which make the magic happen?
But it’s this complexity that gives our world its richness, and we have no option but to embrace it.
Thinking about the problem
In her landmark review Dame Carol is very clear – “funding cuts have left treatment and recovery services on their knees”. She describes a workforce drained of morale – with caseloads and complexity up, commissioning capacity and access to specialist roles down. But she also prescribes a remedy – a competent, well-supported, multi-disciplinary workforce as the cornerstone of change.
Dame Carol’s views have now been endorsed by the state in the shape of its cross-government Drug Strategy and accompanying major settlement. We now have something to rally around. So, what exactly should we do next?
To collectively design and implement solutions, we must first develop a clearer outline of the problems we wish to solve. This is a battle on four fronts.
Firstly, the harrowing funding cuts to local government have emaciated the commissioning workforce, draining it of specialist knowledge as well as capacity. Commissioning is a skilled system-craft that goes far beyond simply cranking the handle of procurement and monitoring top-line data: good infrastructure enables good provision to flourish and change lives. No system can be served by funnelling all resource to a frontline which cannot thrive without the support and challenge of an effective ‘supply line’.
Secondly, the treatment and recovery workforce itself has been battered, and we risk losing experience and expertise just as we need them most. The famine years of austerity have increased stress, Covid-19 has sapped energy, and opportunities to systematically train and progress staff have diminished. Caseloads have gone up, as have levels of poly-drug use and complexity. Anecdotal evidence indicates some people have chosen to leave the field, for stabler, more predictable areas of health and social care.
Thirdly, recruitment and training pathways for vital clinical roles such as addiction psychiatry and psychology have worsened as a result of austerity, system fragmentation and marketisation.
Finally, there are insufficient new entrants to the workforce. A sense of social justice can be a powerful motivation to work in drug and alcohol services, but awareness of the field in broader society is low and starting salaries are not particularly high either.
There are also wider societal factors at play. Has the move to remote work caused by the pandemic loosened bonds between employer and employee? In a fast paced jobs market, are young people quicker to move on in search of personal/professional value alignment? How is Brexit shaping the relevant job market?
Thinking about solutions
There is much to welcome in Dame Carol’s word-view, and the Drug Strategy which embodies it. But her vision will only become a reality if the Office of Health Improvement and Disparities (OHID), providers, commissioners and lived experience-led organisations can adopt a systems leadership approach to grasp the nettle together. No remedy is alone sufficient and all must be pursued in parallel.
The strategy contains the crucial commitment of the Department of Health and Social Care (DHSC) working with, and crucially funding, Health Education England (HEE) to lead on a full workforce strategy covering not just the relevant medical roles but also ‘drug and alcohol workers’ and ‘peer supporters’. This commitment should be enthusiastically supported by the whole field. Having an ‘establishment’ organisation leading this priority will give it welcome heft.
However two risks present themselves. Firstly, HEE is being absorbed into NHS England which will may necessarily focus attention elsewhere. Secondly, timing. With political expectations rising following major investment, the three-year timescale for transformation does not feel very long and the development of a comprehensive strategy could, understandably, take some time.
And while Dame Carol’s recommendation of a multi-disciplinary national Centre for Addictions in the mould of a royal college is a laudable one, it is perhaps likely to be a slow-burn development amid competing demands.
Taking the four identified challenges in turn:
On the first, commissioning capacity and capability must be built back into the system, with the centre giving a strong signal that local areas should invest in these functions. Commissioners can build on the good work started by the English Substance Use Commissioning Group by continuing to self-organise, sharing good practice and inspiration, with support from OHID’s regional teams.
On the second, the attractiveness of drug and alcohol work can be improved to retain and develop staff, with the centre again signalling the possibility of incoming resource being invested in salaries as well as growing capacity, and pushing forward the development of competency frameworks. Commissioners should demand attention to attractiveness and training of their providers. Providers should continue to review and improve terms and conditions, invest in training and development and ensure robust and meaningful pathways into both volunteering and paid employment for those in recovery. Collective Voice and the NHS Addictions Provider Alliance should continue to bring providers together to share their learning, breaking down the walls competition has built as we move into the more collaborative era of Integrated Care Systems (ICS) and the new Provider Selection Regime.
On the third, OHID could act as system conveners to bring together relevant parties to create a sense of shared mission and develop solutions to unlock training pathways for clinical roles. Progress can be made on psychiatry and psychology training through genuine collaboration, even if it requires difficult conversations and organisations setting aside historical claims or reservations. If we don’t do this together then we are surely failing the people we serve.
On the fourth, providers should take a lead in exploring options for attracting new workers: building links with relevant university departments; recruiting teams not individuals to develop a sense of shared mission; developing career pathways for both practice and management progression; speaking directly to the values of potential employees by fully articulating how drug and alcohol support work ultimately delivers social justice too; and sharing as much as possible with other providers. Now more than ever we must ensure that people entering the workforce reflect the populations they serve, and bring the cultural competencies needed to engage and support diverse local populations. Both commissioners, by steering providers though the menu of local support options, and OHID, by using its Drug and Alcohol Improvement Support Team to play critical friend to providers and commissioners, have vital roles to play too.
So, what next?
There is a need for the field to rapidly develop a sense of how it will work together to efficiently prioritise this work. These organising principles could be a useful place to start.
- Developing the relationships and infrastructure to enable discussion, share good practice, trial new approaches and celebrate successes
- Harnessing the full wisdom of the system by pro-actively engaging other viewpoints to explore and delineate possible solutions, learning from historic successes and failures and reflecting honestly on progress
- Thinking in multiple timescales; categorising possible solutions as short-, medium- or long-term and ensuring an appropriate mix is pursued at any one time
- Shared leadership, with different organisations and alliances taking on responsibility for different pieces of the puzzle, making clear what support and input they need from the other actors
None of this is easy, but a few things are clear. Getting the workforce issue right underpins almost every other aim of the Drug Strategy. Success does not lie within reach of any one organisation or government department alone. The ‘big ticket item’ of the HEE strategy can deliver a major dividend but may not do so quickly. Systems starved of resource for a long time cannot absorb a deluge of new investment, however welcome. Political attention is high, and policymakers want results fast.
These challenges have dogged us for decades, but the solutions surely lie within our collective grasp. A lack of significant progress during the window of opportunity Dame Carol has opened may be judged harshly by history.