The 2016 drug strategy gives us an opportunity to finally address the deficits in access to mental health services, jobs and homes, which have undermined the recovery aspirations of the 2010 strategy.
Next month the government will begin its formal consultation to inform the drug strategy due in March. So how far has the 2010 strategy delivered its aspirations, and what insights have the last five years given us to help shape drug recovery for the rest of this parliament?
In the 2010 strategy the home secretary set out an ambition to ‘reduce demand, restrict supply, and support and achieve recovery’. The prime minister’s view at the end of 2012 was that this had been achieved: ‘We have a policy which actually is working in Britain,’ he said. ‘Drug use is coming down, the emphasis on treatment is absolutely right and we need to continue with this to make sure we can really make a difference.’
Despite the day-to-day challenges of delivery and the uncertainty of future funding following the spending review, we should not lose sight of the big picture – what the PM said was right in 2012, and remains right now. The policy is broadly achieving its aims and has been built on three pillars: a powerful positive narrative, endorsement of the clinical evidence, and a commitment to continue to invest.
The strategy successfully reframed the treatment system around recovery as an organising principle. The balance between ambition and evidence established a new consensus about best practice, steering clinicians to use opiate substitution therapy (OST) to provide a gateway to recovery for everyone who could take advantage of this opportunity. It also gave a secure place to build motivation and capacity to change for those not yet able to take the next step. This enabled the treatment system to promote recovery at the same time as continuing to deliver crime reduction and public health benefits – the bedrock of the success described by David Cameron, which it would be extremely unwise to unpick.
Crucially the government also backed the strategy with cash. Despite the extreme pressure on the public sector, funding committed to delivering the drug strategy was protected as part of NHS expenditure.
The 2010 strategy got the big calls right. It shaped a new ambition for the sector focused on the individual drug user, reached consensus on how to best achieve this together with wider societal benefits, and gave the resources to enable it to happen. However it also called for supporting action on jobs, houses, mental health, and a range of other crucial interventions which have not been delivered. The task for the 2016 version is to continue to deliver evidence-based, recovery-focused interventions, but to also overcome the strategy’s failures in the following areas:
Until 2014 drug-related deaths had been assumed to be in slow decline. Reversing the dramatic increases reported over the past two years has to be a key priority for the 2016 strategy. The underlying causes of the increase are complex and probably result from the interaction of different factors, particularly the ageing and increasing vulnerability of the population. The first step must be to understand the phenomenon and then resource and implement evidence-based responses.
◾Jobs and houses
“Treatment success has been eroded by the failure to gain stable accommodation and employment” (2010 drug strategy). Unfortunately this will be as powerful a summary of previous failure in the 2016 strategy as it was in its predecessor. The very existence of Dame Carol Black’s review is testament to the failure of the current strategy to route people via treatment into the long-term employment that will help cement their recovery. Collective Voice’s contact with Dame Carol and her team give us confidence that she will provide realistic and deliverable plans to promote access to employment, which if resourced will offer a new way forward. There is no such initiative and therefore no similar optimism on the housing front.
◾Integrating prison and community
The “seamless transition” between prison and community sought by the strategy has not been delivered. Before 2013, prison and community treatment was commissioned as one system. It is now two separate systems with NHS England responsible in prison and local authorities responsible in the community. The added complexity introduced by the “rehabilitation revolution” has created even more opportunities for vulnerable prisoners to fall between the cracks on release.
Every drug strategy has identified a failure to align mental health and drug services as having undermined the success of its predecessor. None, including the 2010 strategy, has been able to solve the problem. In essence this is because the root cause has been, not the failure of drug and mental health services on the ground to work together ( although this is often problematic) but the NHS consistent failure to invest in mental health services. The £600 million investment in mental health announced in the Spending Review provides an opportunity to change this pattern which we must seize.
◾”Locally led, locally owned”
Devolving responsibility to localities to enable “joined up local solutions” to replace “one size fits all top-down targets” was at the heart of the 2010 strategy’s approach to accountability. Local Authorities were allocated treatment resources previously routed through PCT’s in recognition of the NHS historic reluctance to invest in drug and alcohol treatment, and the potential to align drug investment with other LA responsibilities to provide cost-effective person and place-based solutions.
Knitting all of this together would be health and wellbeing boards, which would integrate the local authority’s concerns with the Clinical Commissioning Groups’ (CCGs) continuing responsibility for drug users’ physical and mental health, and police and crime commissioners’ interest in the crime reduction yield from treatment. With some notable local exceptions, very few people would argue that the system is working on a national level. Health and wellbeing boards are understandably focused on social care as their overriding priority. Drug users are not a priority for either LAs or CCGs, and the decline in acquisitive crime which access to drug treatment has helped bring about has eroded the police’s role as local champions of treatment.
Commitment to drug treatment varies among directors of public health who lead on this for local authorities. Public Health England (PHE) has disinvested from its local presence, limiting not only its ability to promote and share best practice, but also the local intelligence it previously provided which enabled Home Office and Department of Health to understand what was really happening on the ground.
From 2018, local control of public health will be further strengthened as the public health grant is replaced by direct local authority responsibility for funding from business rates receipts. Unlike in 2010, drug and alcohol treatment is no longer part of the protected NHS spend but will have to compete for resources in the much harsher local government environment.
Continuing to deliver what has worked and overcoming the deficits will become increasingly challenging over the next four years, as the cumulative 20 per cent real terms reduction in the public health grant, announced in the spending review, removes the stability of investment that underpinned the 2010 strategy. Investment in drug treatment increased threefold between 2001 and 2008, since when it has been broadly flat with a slight decline since 2010, and a significant shift of existing resources from drugs towards alcohol since 2013.
There will always be scope for more efficient use of resources, and the best commissioners are working with providers to use innovation and integration to sustain or even improve outcomes. However too often the response is mechanistic recommissioning resulting in wasteful churn, or to demand reductions in contract price only deliverable through reductions in the quality of delivery. The sector needs to collectively and realistically assess what can be delivered, and the new drug strategy provides a timely opportunity to match ambition with resource.
The ideal 2016 strategy would look very like its predecessor – the key difference being to identify how to deliver the joined-up services everyone has known we need for at least 30 years. Key to this will be how best to champion an agenda that is not a natural priority for most of the individuals and institutions responsible for its funding and delivery. Collective Voice will work closely with government to identify workable solutions to this long-standing problem on behalf of all providers and in the interests of service users, their families and their communities.