Almost invisibly, the UK’s drug problem has shifted from being a youth issue to being concentrated among people over 40. Heroin, the most dangerous of the commonly used drugs of misuse, took hold in two epidemic waves; in the 1980s it was concentrated in working class communities in Glasgow, Manchester, Liverpool and London, and a decade later it was focused in ex-coalfield communities. At its peak, heroin was being used by almost half a million people, typically young men in their late teens and early 20s, struggling with mass youth unemployment.
Subsequent generations of young people continue to use drugs but have turned their backs on heroin, resulting in much lower levels of addiction and associated harm. The dramatic reduction in heroin use in the under 30s has almost halved the heroin using population, leaving behind an increasingly fragile remnant of the original 1980s and 90s cohort living with the long-term consequences of 20 or 30 years of dependent drug use. For many, this is exacerbated by problem alcohol use, poor diet, inadequate access to healthcare, poverty, mental health problems and smoking.
In this evidence, Collective Voice focuses on the adequacy of the current funding and commissioning structures in England to respond to this challenge. The analysis draws heavily on the recent Health Select Committee report “Public Health post-2013” published on September 1st and the report of Public Health England’s Expert Group on Drug Related deaths published on September 9th.
“If you’re born poor you will die on average nine years earlier than others.” Theresa May, July 2016
Heroin use is concentrated among the most vulnerable people living in our most deprived communities. The general levels of health in these communities is poor, the additional burden placed on individuals’ health via a combination of alcohol, smoking and poor diet as much as by illegal drug use, leads to very high levels of coronary heart disease, stroke and liver disease.
Vulnerability increases with age, the long-term consequences of smoking having a particularly powerful impact as PHE estimate 95% of the heroin using population smoke compared to 20% of the general population.
Despite increasing concern about drug-related deaths, the experience of Collective Voice members is that the overwhelming majority of premature deaths of those in treatment arise from the consequences of physical ill-health rather than overdose. This echoes the finding from PHE’s drug-related deaths expert group that in one area an audit of 17 deaths attributed 14 to physical health problems with only one resulting from overdose.
The resources and expertise to respond to these needs lie much more in mainstream NHS commissioned and delivered clinical services than they do in Local Authority commissioned drug and alcohol treatment. Historically the NHS has been poor at engaging with excluded populations and delivering services to challenging individuals. Offenders, the homeless and people with mental health problems often have no GP. They make themselves unwelcome at A&E, they miss appointments, they fail to cooperate and the complexity of their health needs is ill matched to a system which focuses on individual conditions. In many instances the very people who need the NHS most are those who are least able to navigate its various pathways and comply with its expectations.
As mainstream NHS resources are placed under increasing strain, the cultural and structural barriers that tend to exclude the non-compliant become more powerful. There is little political or media interest in addressing this deficit as the denial of services to the” non-deserving” is swamped by increasing concern about the inadequacy of the whole system.
Since 2013, as a consequence of the reforms to health care introduced by Andrew Lansley , public health services including community-based drug and alcohol treatment have been commissioned by Local Authorities , healthcare in prison by NHS England and the remainder of healthcare by Clinical Commissioning Groups. When the new arrangements were instituted it was recognised that the three systems would need to be integrated on the ground despite being commissioned separately. There is a good rationale for Local Authorities to commission drug and alcohol services as their wider responsibilities provide an ideal platform to integrate housing, employment, offending and child protection with clinical services, to maximise the benefits of treatment and promote recovery. However, this needs to be done in tandem with appropriate access to the mainstream health services the population increasingly needs.
Unfortunately, rather than fostering integration, the current arrangements have strengthened and heightened the pre-existing cultural and structural barriers excluding this population from mainstream services. Interestingly, this pertains even when Local Authority commissioned drug treatment is delivered by NHS substance misuse providers. The barriers excluding this population operate just as powerfully within the NHS as they do between the NHS and third sector providers. Meanwhile, drug and alcohol treatment in prison has become disengaged from community provision, which presents real challenges to prisoners on release.
To borrow language from the Health Select Committee, the system is “fragmented” and until it is properly integrated the growing gulf between need and the availability of services will become ever more apparent.
Health & Wellbeing Boards
When the 2013 reforms were implemented, the expectation was that the two systems would be knitted together by Health and Wellbeing Boards, which would act as a shared strategic forum to allocate resources and determine priorities across Local Authority and NHS commissioned services in each area. The Health Select Committee uses measured language in its report but nevertheless identifies Health and Wellbeing Boards as failing to live up to the expectations of the original blueprint. It is particularly concerning that NHS commissioners were prepared to go on record to tell the Committee they do not value them as a venue to undertake shared business. Even in the minority of areas where the Boards are fostering partnership working this is inevitably focused on priorities such as social care rather than lower order priorities such as drug and alcohol treatment. In a recent national forum for drug and alcohol commissioners held by Collective Voice only one Local Authority area reported engagement with their Health and Wellbeing Board.
The failure of Health and Wellbeing Boards is particularly important for the drug treatment sector. Drug misuse is not a natural priority for either Local Authorities or the NHS. Compared to tobacco, alcohol or obesity, illegal drug use generates relatively little health harm at a population level. Over the past 20 years the main driver of investment in drug treatment has been the significant impact treatment access has on offending. Health and Wellbeing Boards were designed to be the local forum where the wider societal benefits of investment in drug treatment could be reconciled with all the competing local demands for scarce resources. The failure of Health and Wellbeing Boards to meet this expectation leaves drug misusers and the services that treat them without a point of influence in local systems.
Local Authority and NHS provision is under significant financial strain. Cash increases in NHS funding are failing to match increasing demand. Local Authorities have absorbed cuts of up to 30% across the entire range of services they provide. The Health Select Committee estimates that the real terms reduction in public health budgets during the spending review period will be around 15%. Collective Voice analysis identifies cash budgets committed to drug and alcohol treatment across England as £1.2bn in 2012/ 13 reducing to just over £800m in 2016/17, a 32% reduction. This national figure masks even more significant reductions in particular local authorities.
The Health Select Committee reported that the flexibility and innovation shown by Local Authorities has enabled them to protect their populations from the full impact of these cuts, but that their capacity to recast systems and drive efficiencies can only be taken so far before negative impacts begin to show through. Collective Voice members’ experience echoes the Committee’s analysis. It is becoming increasingly common for providers to choose not to bid for contracts to deliver services because the resources committed by the Local Authority are insufficient.
The consequences of disinvestment disproportionately affect older populations as they are more likely to be users of a range of public services, all of which are under strain, resulting in a significant cumulative impact on their lives.
Impact on the NHS
The Health Select Committee’s view is that disinvesting from public health in general is a false economy. This was emphasised in respect of reductions in drug and alcohol treatment in the strongest possible terms by Simon Stevens, Chief Executive of NHS England, in his evidence to the committee:
“At the very least, we wanted the availability of preventive services to be sustained relative to need. An area where you get 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 those 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 long-term consequences to scarce NHS resources of the failure to enable access to mainstream NHS services is at least as significant as the failure to invest adequately in drug and alcohol specific services. Denial of services to this population is a short term fix for the NHS bought at the cost of significantly increased costs in the long term.
The most recent ONS analysis of the rise in drug-related deaths in England, supported by PHE’s expert group, points to the increasing vulnerability of the ageing cohort of 1980s/90s heroin users as the single most significant driver of deaths. Although most deaths of this population are not attributable to overdose or suicide, the long-term increase in drug-related deaths is the most visible and most politically salient manifestation of an otherwise largely invisible problem. Collective Voice is working with the rest of the treatment sector, including NHS providers and PHE to do what we can to identify those most at risk and intervene appropriately.
The dominant theme in drug treatment policy in the 1980s was HIV, the dominant theme early in this century was crime. Responding to the needs of this ageing and increasingly vulnerable population is emerging as the dominant theme of the current era. Unlike earlier crises it is unlikely that additional resources will be made available to respond. In part, this is because we live in austere times, but it also reflects the uncomfortable reality that as this population ages it becomes less of a threat to wider society and can more easily be ignored.
Collective Voice welcomes this enquiry as one of the means to raise the profile of this issue and identify solutions. The evidence we have presented focuses on the inadequacy of the structures we currently have to respond to this challenge. We do so in large measure because the modest changes needed are deliverable in the current financial climate. Fragmented systems are particularly unsuited to dealing with vulnerable populations who have spent much of their lives falling between the cracks in all our services. At the very least we need services able to meet their needs, not continue to impose our expectations on them.